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T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. rr �••�J� ASO` X�.7O z PM Job Address City- ` Lot Size �a0 { Phone3_6 TZ .Owner's Name -'7 Address Contractor �yC? d� Address 1-2S I4� ��/License No.?O 3-9'2-1 Phone3P�'4�� 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 FOUNDATION AGRICULTURE WELL . OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a f°l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -- I i Irrigation --Approx. Depth l I Eastern Surface Seal Installed by '-Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1vl' REPAIHIADOITION 1.3 DESTRUCTION I 1 allo septic system in emitted if public sewer is i eet Installation will serve: Residence 1.1-1 Commercial'_ Other C' Number of living units: I{ Number f edrooms -3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E4- Type/Mfg Coo '4.01 Capacity GU No. Compartments m PKG. TREATMENT PLT. LJf Method off Disposal Distance to nearest: Well Foundation /o Property Line�/ �/�� r i LEACHING LINE No. & Length of lines ~4 r Total length/size LSI FILTER BED CsYDistance to nearest: ' Well Foundation'422 Property Line o20 u _ SEEPAGE PITS hi' Depth a`Az_ Size_�_ Number F SUMPS ❑ Distance to nearest: Well OD r Foundation e-2_1f`;:— Property Line 70._— i "� DISPOSAL PONOS 17 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ounty ordinances, state laws, and 3 rules and regulations of the San Joaquin Local Health District. �_ rs5 Home owner or licensed agent's signature certifies the following: "I certify that in,the performance of the work for which this permlt is ued, L 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 k 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 cc mpensa tion laws of California.'; The applicant must call for all equired inspections. Complete drawing on reverse side. X Title: - Date: Signed OR DEPARTMENT.USE ONLY .- .•. . - �� . + Application Accepted by date 1 Cl- Area bt r Grout Inspection by ate `� Final Inspection by �91 e -- Date _ t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 a Manteca 823-7104 © Tracy 835-6385 Applicant- Return all copies to: Environmental-Health Permit/Services.1501 E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO + 32-1 EH 13-24(REV.t i n 51 ell, (} / �f 4 EH 14-26 L