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(. � kt� APPLICATION FOR PERMIT q u SAN JOAQUIN LOCAL HEALTH DISTRICT, f 1601 E. HAZELTON AVE., STOCKTON, CAS' _ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � >��C�IC�S (Complete in Triplicate) > > R. i application is Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This APP urn County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin ' Local Health District. PM City s Lot Size Job Address 7/ Phone �7 %7/14 Address Owner's Name /c �J�7�e phone � —.` A ��C—fticense Na. Address, ^— DESTRUCTION ❑ Contractor WELL R EPLACEMENT ❑ NEW WELL ❑ _ OTHER ❑ TYPE OF WELL/PUMP: PROP. LINE PUMP 1NSTALL.ATION �y �"�'pi��SYSTEM REPAIR DISPOSAL FLD. - ,I DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES _ �--—.—�--- OTHER WELL PtTS1SUMPS - FOUNDATION -- AGRICULTURE WELL �— — A INTENDED USE TYPE OF WELL PROBL� MAREp CONSTRUCTfON SPECIFICATIONS pia. of Well Casing f eBottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Industrial Op.n o Ll Tracy Type of Casing Type of Grout -- ❑ Domestic/Private Gravel Pal F1 Delta Depth of Grout Seal �.l n Public f_� Other f - pprox Dept;t _ 1�. astern Surface Seal Installed by t A ' I Irrigation = State Work Done r. Repair Work Done ❑ Type of Pump H.P. Material 4p 50'1 a Diameter _1 Sealing Well Destruction ❑ Well .I Filler Material (Below 50'1 Depth thin 200 fel l ESTRUCTION l 1 (No septic system permitted it l TYPE OF SEPTIC WORK: 'NEW INSTALLATION l l REPAIR available w /ADDITION`-1.1� r� public sewer is dll Other i Commercial installation will serve: Residence' t ` , Number,of be odms` -. .4 tti� NVater table deptfl Number of living units: 4y=� �i Character of soil to a depth of 3 feet: ,apacity�� No. Compartments I SEPTIC TANK ❑' Type/ � ' i Method of Disjposal r � I PKG. TREATMENT PLT. ❑ IIIproperty,Line +/I ' We Flio"n' ��— Distant a to �crest: s •Lam~ ❑� Na'&`Length as Total length/size LEACHING LINE Foundation Property Line FILTER BED 01 Distance nearest: Well ��r1 I t I Number SEEPAGE PITS l I1 Dept Size property Line Well Foundation SUMPS ❑l Di rice to nearesi: 4, ;,,� i f. DISPOSAL PONDS ❑ s i certify that i have arepared this application and that the work will be done in accordance with San Joaquin county ordinances. state laws, and I hereby ce y rules and regulations of the ESan Jogaquin Local Health Dtrict.g certify work for that in the Home owner or licensed agent nef as to become subjecplto wrarkman'scompensation lawsofperformance aha Contractor's olhis ngch I orr sub-contract'rtgs peri-nit is issued, lsignatushall �e employ.any person in such ma y , certifies the foklowinn: u certify that`in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compel tion laws of California." 1 applicant r requir i ctions. Complete drawing on revers side. //` The app• TitlDate: �• �. Signed X !! FOR D PARTMETIT USE ONLY i 1- Date 7_�� U Area Application Accepted by v pate Date Final Inspection by Pit or Grout Inspection by l Additional Comments: El Sik 466-6781 ❑ tol :369 3621 D Manteca 8237104 ❑ Tracy 835-6385 Applicant Return ail copies to: Environme}}ntal Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i J 3 CK RECEIVED BY DATE PERMIY NO. FEE AMOUNT DUE I AMOUNT REMITTED CASH INFO a.EH 13-24 1REV. - EH 14.28