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1 APPLICATION FOR RERMIT SAN JZ(i6'fiV LOCAL HEALTH DISTRICT X 1601.e HAZEL T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 ; PERMIT EXPIRES '! YEAR FROM DATE ISSUED {Complete in TripJjcate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thrr work herein described. This application is madein compliancean Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distri t� ; Job Address y City. Dp-t Lot Size r PM Tam �llZ.E9�9A1 t ;!I _ 2 t Owner's Name Address Phone �3 � Contractor DD S Address , lt� +�� D 21� License No. �d 16 Phone TYPE OF WELL/PUMP: II NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑` PUMP INSTALLATION f SYSTEM REPAIR ❑ OTHER D f i DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES '""` DfSPOSAL FLD. PROP. LINE _ 169PFOUNDATIONS- AGRICULTURE WELL �— OTHER WELL PITS/SUMPS L' ffi INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 R)Domestic/Private AyGtavei Pack ❑ Tracy Type of Casing_ IL1Z Specifications C1 Public ��❑77��O'her ❑ Delta Depth of Grout Seal ', Type of Grout_�Q I I Irrigation 6�7Approx. Depth I 1 Eastern Surfa a Seal Installed by Repair Work Done ❑ Typelof Pump H.P. 1 3� State Work Done , y Well Destruction ❑ Well,`Diameter Sealing Material Itop 50'1 J Depth Filler Material {Below 501 c TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 {No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bediaoms a Character of soil to a depth of 3 feet: Water table depth i SEPTIC)TANK ❑ Type/Mfg Capacity No. Compartments PKG.F„REATMENT PLT. ❑ II Method of Disposal r. Distance to nearest: Well Foundation Property Line ! LEACHING LINE ❑ No. & Length of lines Total length/size % I FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; 4t y SEEPAGE PITS i I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cbuniy ordinances, state laws, and rules and regulations of the San;Joaquin Local Health District. Home owner or licensed agent's psignature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California.” 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." The applicant m ti'i a wired i e Complete drawing on reverse ide. I Signed X_-_ Title: �� Date: FOR DEPARTMENT USE ON Y j Application Accepted by Date �` J� Area } _4�y Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all,`copies to: ``Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II. INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT ND. +.EH13-29{HEV.1/)15) EH t4-2B 4