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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ?R Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in 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. , Job Address oeff 92 .2 C° City Lot Size .4 e—IME — PM �. j!�/f` Addresses Phone Owner's Name�� i- Ph cense No. Contractor's Name g g A� l'r�` �`_6`C — '3 one TYPE OF WELL/PUMP:I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION-L) - %SYSTEM REPAIR ❑ OTHER ,111 DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL•FLO. PROP. LINE I I j FOUNDATION "N 'AGRICULTU'RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL: PROBLEM AREA !CONSTRUCTION SPECIFICATIONS EJIndustrial ❑ Open Bottom it -❑-Manteca. 1Dia. of Well Excavation Dia. of Well Casing p } ❑ Domestic/Private ❑ Gravel Pack. x ❑ Tracy Type of Casing - Specifications C1Public ❑ Other , • ,, ❑ Delta Depth of Grout Seal Type of Grout d ❑ Irrigation ----Approx. Depth ❑,Eastern Surface Seal lnstalled.by Repair Work Done ❑ Type of Pump ` H.P. State Work Done Well-Destruction ❑ Well DiameteySealing Materrl (top 50'1 a ; i-, .-. Depth -N:,. I I Filler Materiall(Below 50'] TYPE OF SEPTIC WORK: NEW INSTALLATION ❑'"REPAIR/ADDITION DESTRUCTION'❑ (No septic system permitted if public sewer is j 1 I iavailable within 200 feet.) Installation will serve: Residence DtherI'Commercial �� f' Number of living units: �- Number of bedrooms -�,ble depth � Character of soil to a depth of 3 feet: Water#a I Capacity = No. Compartments SEPTIC TANK ❑ Type/Mfg � �y -_—.---.r r {� PKG.- TREATMENT PLT:❑ Method of Disposal "9-1 Distance td nearest: Well Foundation t Property Line j t f F 1 otae`m � s LEACHING LINE ✓No. & Length of lines ' T ! length/slzr FILTER BED El Distance to nearest: Well ;� x'—'Foundation _- Property Line SEEPAGE PITS !"' Depth Size F I Number SUMPS I❑ Distance to nearest: We .i_ Foundation__•" .-..— Property Line -` 6 DISPOSAL PONDS ❑ _ -- -- _ hereby certify that l 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 District. r licensed agent's signature certifies the following: '9 certify that in the,performance of the work for which this permit is issued, I shall not Home owner or employ any person in such manner as to become subject-to workman's compensation Paws 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." I The applica st call for all required inspections. Complete drawing on rever dqzw Date: f2 Signed Title: FOR P R ENT USE ONLY IC' Ar r Application Accepted by Date / Date ` Final inspection by - Date Pit or Grout Inspection by Additional Comments:,' �� r .~.. •- � _ ' ❑ t 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 µ 171 Tracy 835.6385 .r Applicant- Return all copies to: Environmentak Health Permit/Services 160cK W-71 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE to AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO �� +EH 13-241REv.16!93} �"yy1s< 4 E '_k/$111 +~g L ' EH 1426