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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r ` 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Q' 5 CsQ ,� ►K Application is hereby made to'he San Joaquin Local Health District fora made H compliance with San Joaquin County Ordinance No.549 for sewageeor.No. 1851 for install the work he Rules and Re�ulations of the San J �i i Local Health District. � ascribed.This application is l 4 � I P P oaquin Job Address (] City Lot Size PM t Owner's Name 402 3 Phone �. Contractor— "Se 1� i ,Address TYPE OF WELL/PUMP: -1[1P NEW WELL ❑ License No. phone ' WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 PU I P INSTALLATION ❑ SYSTEM #EPAIR ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ --.�_ SEWER LINES -•-- -_ DISPOSAL FLD. PROP. LINE Q� FOUNDATION y AGRICULTURE WELL - "� 1' INTENDED USE = OTHER WELL t PITS/SUMPS TYPE OF WELL PROBLEM AREA' ❑ Industrial CONSTRUCTION SPECIFICATIONS ' ❑ Open Bottom ❑ Manteca* pia. of Well Excavation x ❑ Domestic/Private v O Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing-----!------J ❑ Public ❑ Other specifications ❑ Irrigation �R Delta , r.,Depth.of Grout Seal # �Approx. Depth ❑ Eastern ' - f'' a Type of Grout Repair Work Done ❑ Typelof Pump Surface Seal Installed by r- ��d---Y� J Well Destruction ❑ H'P' State Work Done Well Diameter ' Sealing Material {top 5011 Depth # Filler Material (Below 5o') Y+ ' TYPE OF SEPTIC WORK: 1VE INSTALLATION 0 REPAIR/AD,DITION ❑ DESTRUCTION :� A {No septic system permitted if public sewer is 1 Installation will serve: Reside I ce Commercial F —1 availbble within 200 feet.) Y Other. � � � Number of living units: �� Number of bedrooms Character of soil to a depth of i3 feet: SEPTIC TANK -2Water table depth ❑ Type/Mfg 1-L Capacity _ PKG. TREATMENT PLT. 11 No. Compartments I.. Distance to nearest: Wel! Method of Disposal Foundation Property Line ! LEACHING LINE ❑ No.!& Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size 4 Foundation_ property Line SEEPAGE PITS ❑ Depth SUMPS Size Number ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ I! _ Property Line . I hereby certify that I have prepared this application and that he work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Jgaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify performance rco that in theofCalif rn the work for which this permit is issued, I shall not amp oy.any person in such manner Fos to become subject to workman's compensation laws 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 tion laws of California." p y Persons subject to workman's cam 0 The applic m st call for all !red ins ctions. Complete drawing on reverse side, Dense .iE. Signed Title: Date: FM DEPARTMENT USE ONLY Application Accepted by ;1111: 2:2111111, 1 Pit or Grout Inspection by II Date Area, Date Final Inspection by Additional Comments: II Date I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 8 Applicant- Return all copies to: Environmental Health Permit/Services 1601 EO azef<on AAvee4MP.O. Box 2009, Stk., CA 95201 FEE AMOUNT 06 CK INFO � AMOUNT REMITTED RECEIVED BY II``II DATE PERMIT"NO. +EH 13-241REV.i/a 3 51 HN ��' ,+1� EH 14-26 Ip' 0 V AV -�-7 .Sz 'I