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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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 �s � City +r Lot Size / PM Owner's Name VJ& Address - __ ---- Phone oLrntractoj �� may' Address �'~ License No 3 � Phone TYPE F WELL/ MP:` NEW WELL ❑-r''� WELL REPLACEMENT ❑ DESTRUCTION ❑ �-_ T E 0 .,�.�, F _ � �A PUMP IN TA�L TION ❑ SYSTEM REPAIR 0__ OTHER ❑ 1� t DISTANCE TO NEAREST-SEPTIC TANK SEWER LINES--' 'DISPOSAL FLD. J',J'r PROP. LINE � - - FOUNDATION AGRICULTURE-WELLOTHER WELL PITS/SUMP s _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation ''fir Dia. of Well Casing F-1 Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing t?"6" 's1 `-. Ir Specifications . n i`I Public Cl Other if7:Delta Depth of Grout-Seal--- ys Type of �irgpti'` 1 Irrigation 1ppfox. Depth I I Eastern Surface Seal Installed by L-.--s• i Repair Work Done ❑ Type bf Pump. 41-f'---- --=----=- State Work Done Well Destruction (-❑M-Well piameter------ ^— Sealing Materialltop 50') 4 1 Depth Filler Material /Below 50') x" — TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION {',I DESTRUCTION I I (No septic system-permitted if public sewer is available-wifhin 200 feet.I Installation will serve: Residence Commercial_ Other ) I Number of living units: Number of bpdrooms _ t Character?of soil to a depth of 3 feet: 1 \C C' -' t Water table depth v i SEPTIC TANK LlType/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ t Method of Dis sale 3 �s_Distance_to nearest: Well-1 ,_ Foundation Property Line v it +LEACHING LINE � __ tj No. & Length,pf € Total length/size . FILTER BED Cl Distance to'nearest: Well FounLtion Property Line SEEPAGE PITS I I Deptli 1 Site Murpber i fj l s' I ,� Ty' i 1 SUMPS PCEJistance to;nearest: a Well ( Foundation l�D Property Line s DISPOSAL PONDS ❑/ } 1 . I hereby certify that I have/prepared this application and that the work willbe done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of tAe San Joaquin Local Health District. f{ Home owner or licensed`agent's signature certifies the following: "I certify that in the performance of the work for which this perrtiit is issued, I shall not I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's(tiring or su -contracting signature certifies the following: 'jI 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 s 1 I The applicant must cal afl required inspections plate drawing on reverse side. veSet) �� Signed ( ' Title: - Date: i R ARTMl:NT USE ONLY Application Ac pp ceptedlby date ATea- Pit or Grout InspectiA by Date Final Inspection by date Additional Comments'. f _ ± t t l _ x� !❑ Stk 466-6781 EI Lodi 369-3621 1-1 Manteca 823J104 ❑ Tracy 83516385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton A,'e P.0. Box 2009, Stk., CA 95201 1 FEEAMOUNT pUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT'NO. g ..-INFO'"-'""'" CAS H ♦ EH 13-24 4REV. /H 5) EH 14-2e A