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1'17 APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA a i Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) is heieb made to the San Joquin Local Health District for a permit to construct and/or install the work herein described- This application is a Application Y made compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I r � ��r• � f City Lot Size PM• Job Address Phoneto {y-- 7. + tr + Address Owner's Name � ` e4 Address � � ////� Address �� X �– License No, 3 Phone N Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR 11OTHER El PUMP INSTALLATION Lar DISPOSAL FLD. PROP. LINE SEWER LINES, DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS �. FOUNDATION AGRICULTURE WELL 3 INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing El Industrial 1d ❑ Open Bottom Ll Manteca Dia. of Well Excavation Specifications 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing a ❑ Cl Other ❑ Delta Depth of Grout Seal Type of Grout Public If I I Irrigation �-.Appro>� Depth I I Eastern Surfa a Setif installed by 1 �{ _ �� H P / � - State Work Done �r 1�✓e'z`'t'�--� Repair Work Done i� Type of Pump Ai � Well Destruction 11Well Diameter T- Sealing Material Itop-50'1 Depth I Filler Materia! {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I °-REPAIR/ADDITION I 1 DESTRUCTION I I available within Sy in 200 fetem e`tled it public sewer is Installation will serve: Residence Commercial— Other I E t/t Number of living units: Number of bedrooms + c. Water table depth Character of soil to a depth of 3 feet: ❑ Type/Mfg Capacity No. Comp'3rtn s �r SEPTIC TANK _ � . ..>. --, Method of Dassal k PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Wel! Foundation ( r f + 1 Total length/size p LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED L1 Distance to nearest: Well Founation p y �i,k` Ili,•_;:\I��(a,.L( :L-; I �:'�Vi##lvkl?1rlr-err I 1 Depth I Size Numbef SEEPAGE PITS Property Line SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ f I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and -rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Calif ornia.•' Contractor's hiring or sub contracting signature certifies the following:"I certify that in the performance of the work for which this-permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 11 The applican must call for all renquuired inspections. Complete drawing on reverse side. U, Signed X a✓` �'" "ditle: Date: FO EPARTMENT USE ONLY Date Area �'� Application Accepted by Dae Final Inspection by , Date J2�= Pit or Grout Inspection by E 1 Additional Comments: ❑ Stk 466-6791 11 Lodi 369-3621 ❑ Manteca"'823-7104 ❑ Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE CK RECEIVED BY DATE PERMIT•NO. AMOUNT DUE AMOUNT REMITTED CASH F INFO +.EH 13-24(REV,i/A 5) EH 14-26