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^ k APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 v PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri pP bed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage a5- No. 1862 for well/pump and the Rules and Regulations of the San Joaquin � Local Health District.S �N'� S, NW l'T a &etuie> Job Address uS7lN A 9 / l0Ly�'r46 G city i RoAi .Lot size -/.. l`� `�c— P 7 Owner's Name fes- w R 110';i r Address fa [J Phone `""c_� _!/ g �� T License No. ,0 l Phone Contractor's Name TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ { PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �..� z FOUNDATION -----="AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA` CONSTRUCTION SPECIFICATIONS L1 Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation "�' Dia. of Well Casing ❑ Domestic/ Private L1 Gravel Pack ❑ Tracy Type of Casing — Specifications ❑ Public ❑ Other ; ❑ Delta Depth of Grout Seal- Type of Grout _ © Irrigation --Approx.j Depth ❑ Eastern Surface Seal Installed by _. Repair -Work Done [IType of Pump} H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW,. INSTALLATION PAIR/.ADDITION ❑ DESTRUCTION 171(No septic system permitted if F p f available within 200 feet.l "'t - Installation will serve: Residence Commercial Other + j Number of living units: Number. of bedrooms- -- �" Character of soil to a depth of 3 feet: 4A60 Water table depth SEPTIC TANK Ty /Mfg 2e. j Capacity &a_- 'L No. Compartments— PKG. TREATMENT PLT. ❑� �I i Method of Disposal Distance to nearest: Well ©� Foundation Property Line % s k g LEACHING L•`INE ❑ No. & Length of lines Total length/size FILTERiBED ❑ Distance to nearest: Well 40 Foundation _ r Property Line ubiic sewer is t i A0 SEEP GE PITS ❑ Depth 1 Size Number. 1 S SUMPS ''t '❑ Distance to nearest: Well Fou Iclation Property Line ty DISPOSAL PONDS ❑ } i hereby certify that I 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. Home owner or licensed agent's signature cert'rfies 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 California." Contractors 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 compen C,--tion 'laws of California." w 1 k The applicant must call for all required inspect' ns. Complete drawing on reverse side. / Signed ,( Title: Data: Vk- �e'� I f � FOR DEPA MENT USE ONLY �� Date J' 0 Area — Application Accepted by r C S t r f Pit or"Grout Inspection by Date Final Inspection by _ Date -Add nal Comments: " - [ El Stk +466-6781 ❑ Lodi 369-3621 Manteca 823-7104 C7 Tracy 835-6385 r i- Applicant - Return all copies to: Enviro6mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I + EH 13-24 (REV. 101831 EH W28 FEE INFO AMOUNT DUE t'c AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT"N0. L s�f