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-,.APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE.', STOCKTON, CA Telephone {209} 466-6781 f PERMIT EXPIRES 1 YEAR FROM DATE 1SSU'ED" ,-.�` (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Ryles and Regulations of the San Joaquin Local Health District. !®`� �Yom'/V ' VY 1\�l `/�A Ci 0 d Lot Size PM Job Address iw I j ---Owner's Name �Ag4Address- ��1 � — Phone 77 d��pp A� �PT e Address �� 6 J 0 X License N0. C� Phone �I r "2j� 0ntracTOr TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION . SYSTEM REPAIR El OTHER C1t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ o ❑ Industrial ❑ Open Bottom ❑,Manteca Dia. of Well Excavation Dia. of}Well Casing ` Domestic/Private El Gravel Pack 1-1Tracy '' Type of Casing Specifications i ❑ Public 171 Other ❑ Delta), '; Depth of Grout Seal Type ofiGrout ❑ Irrigation pprox. Dept astern' � Surface eal Installed by Repair Work Done Type of Pump SL_ H.P. State Work Done A E �M 9 Well Destruction ❑ Well Diameter Sealing Materiailtop 501 Depth Filler Material (Below 50) TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public,sewer is available within 200 feet.) f Installation will serve: Residence_ Commercial— Other "t 3 . 4 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t j Distance to nearest: Well Foundation Property Line r I - � k. LEACHING LINE ❑ No. & Length of lines Totai length/size- FILTER ength/size FILTER BED ❑ Distance to nearest: Well Foundation—.Property Line , SEEPAGE PITS ❑ Depth Size - Number^'-I' i SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ R _�`" * '` I ` I' ne intaccor&i&c iWiith San Joaquin county`ordinances°seats laws 'and 4 I hereby certify that I have prepared this application and that the work wdl be do 1 I rules and regulations of the San Joaquin Local Health District. t l< 1 E ) Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issLied, I shall)not I employ any person in such manner as to become subject to workman's compensation laws}of California."Contractor's hiring Eor sub-contracting signature I certifies the following:"I certify that in the performance of the work•for,which•this:permit•is,issued,-I'shali-employ persons subject to work�ina h's compensa- tion laws of California." The applicanj MUst II f r II re uired inspections. Complete drawing on revs •de. ! Date: Signed FOR DEPARTMENT USE ONLY I _ Area / •�.� I, �Applic`afion Accepted-by`` - -- Daatete ' � - 's Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: :. ❑ Stk 466-6181 ❑ Lodi 369-3621 '� Manteca)823-71104 1 CD Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I "FEE AMOUNT DIJE AMOUNT REMITTED GASH,- RECEIVED BY DATE VERMIT'NO. k INFO ` g +EH13-24(RFV.I/a5) ` s tT EH 14.28 `44-�� _Q15 -