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I --� APPLICATfON FOR PERMIT SAN JOAhQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA iTelephone {209) 466-6781 i PERMIT EXPIRES TYEAR FROM DATE ISSUED k N (Complete in Triplicate) I 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 E Local Health District. _&L Job Address City Lot Size PIM Owner's Name Address Phone j Contract Address V License N133872:Z" Phone_ ' OF WELL POMP:7- — NEN WELL❑ ' ELL REPLACEMENT- [] xDESTRUC-TION-7 PUMP INSTALLATION --�- E l SYSTEM REPAIR❑ OTHER ❑ � •, �-� III DISTANCE'TO NEA10EST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f -='s< FOUNDATIOI4 's'�� - AGRICULTURE WELL �'� OTHER WELL- PITS/SUMPS„_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y` -❑ Industrial' ❑ Open Bottom ❑ Manteca Dia. of Well i Excavatio6 Dia. of Well Casing t C7 Domestic/Private L1 Gravel Pack CI Tracy I Specifications 1-1;Public 1-1 Other t. F1 Delta, Depth of Grout Seal Type of Grout _ I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by' r ? r - - ti-Repair Work Done ❑ -Type of Pump' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material''-)-top 501 I Depth 1 •)ler Material EBelc4_50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 ;jEPYlfADDITION DE5TRUCTION I 1 {No septic system permitted if publicsewer is I /f� ?. available within 200 feet.) tnstaltation will serve: Residence_ Commercial 4 Other t y Number of',living units: C2 Number f Character of soil to a depth of 3 feet: �� rti';a"+r-� -Water table depth SEPTIC,TANK ❑ Type/Mfg 'IM Capacity "' rt No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal - Distance to nearest:-» YWell,----- .�odndation� _"P�operty,Line „ S LEACHING LINE ❑ No. & Length of lines I`- yr ti t 9 Total.lengthlslze FILTER BED EDistance to nearest: Well; Foundation f°{!� Property Line SEEPAGE PITS . �/ -- �t�'I Depth Siza�t ��.• *�`F Number SUMPS It f 0', Distance to nearest: Well " f j k %.� _....___-._ Foundation ,f� . ,Property Line --DISPOSAL--PONDS ❑ 1 hereby certify that I have prepared this application and that tKS `work will beidone in aic'ordance with San Joaquin,county ordinances, state laws, and ,i�fules and regulations of the San Joaquin.Local Health District. Home owner or licensed agenIT-signature certifies the f4owing: "I certify that in the perforimanc of the work for which this permit is issued, I shall not employfany person in such mannei�hs to become subjemto,workman's-compensation-laws of"California-"Contractor storing or sub-contracting signature ceiYifies'ihe following: "I certify thai1ri the performance of the work for which this permit is issued, I shall employ pe sons subject to workman's compensa- tion laws of California."The appfic`ant must c 'for allreq it i ctions,-Complete-drawing on re�v}er�sesi e , Signed"X T ITitle: C Date: I !f s FOR DEPA fAENT USE"ONLY w�= Application Accepted by Date ^J I 'r�C3Are Dit rGrout Inspection by Date' Final Inspection by Additional Comments: `� -u w11 - 'c , LI Silk 466-6781 ElLodi), 3699-3821 [� 'Manteca 4.923=7104 ❑Tracy 835-6385 ; Applicant - Return all copies to: Environmental Health Permit/Service`s'1Ell E Hazelton Ave., P.O. Box 2009, Sjk,i ,CA 95201 FEE CK t INFO AMOUNT,DUE ; AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. + EH 13-241REV.I/ 1� EH 1428