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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209).466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs application is I 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. '1 7 Rcc x)Ck City t,�d,C1 Lot Size �` S PM Job Address �.- - , Owner's Name —)nAi FvtT Z Address - Phone - r Contractor Commike. Address ISO Z,� �Ue License No.2y �1 g Phone TYPE OF:WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1,0 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ~� ¢,OTHE_R WEE PITSmMPS INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1:1 Industrial Ll Bottom ❑ Manteca Dia. of Well Exc�iation b Dia. of Well Casing ❑ Domestic/Private E.Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑Other ❑ Delta Depth of Gr out Seal Type of rout t� ❑ Irrigation -L—Approx. Depth ❑ Eastern surface SX Installed b> i - er�h Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materiaop 501 " I Depth Filler Material (Below 501 a I TYPE:OF,SEPTIC WORK: NEW INSTALLATION 16 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is +, available within 200 feet.j i Installation wi ljserve: Residence Commercial, Other r Number of living units: Number of bedrooms 3 �f n✓ fCharacter of soil to a depth of 3 feet: � �l Water table de th bi SEPTIC TANK Type/Mfg E-L f Q O Capacity__I No. Compartments V_ PKG. TREATMENT PLT. ❑ r r Method of Disposal F !Distance to nearest: Well �� Foundation b Property Line I .....:-..�- —. , LEACHING LINE No. & Length of lines # " Total length/size ' ' /qtyFILTER BED El ,Distance to nearest, ell Found}}tion Property Line SEEPAGE PITS 631.1 Depth 0 /Size X�b 7/011- i #{ Number SUMPS ❑ 'Distance'to neerestb Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application anal that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local iliealth'bistrict. a M Home owner or licensed agent's signaturcertifies the:f6Howing:—'I de—F6fnhat iif the performance of the ork 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." ontractor•s hiring or sub-contracting signature certifies the following:"I certify that in the perfoance of the work for which this-permit is issued, I shall em p Signed persons subject to workman's compensa- tion laws of California." t The applicant n Ust.Gall for all re uired ins ctions. Complete drawing o1w reverse side. j /C,y yt- Titief Date: FOR DEPARTMENT USE ONLY �� 06- Application Accepted b � Date Area� Pit or Grout Inspection by NJA Date Final Inspection by , Date( Additional Comments:' ❑ Stk 466-6781 ❑ Lodi 369-3621anteca 823-7104 "'O Tracy 835-6385 V Applicant - Return all copies to: Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` �.._..._,�- ..,�......_..:...g,-- � �—.�,..,.mow.:.-,...,.......:=..wa..�,.e.-.,,., FEE AMOUNT DUE AMOUNT REMITTED C J RECEIVED BY I DATE PERMIT'NO. INFO + EH 13-24(REV.1/e 5) EH 14-26