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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 4 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 l Local Health District. I Job Address / Jae> City_ Lot Size PM Owner's Name /� � �� Address Phone 49'� Contractor S Are s License No. Phone �� k TYPE OF WELL/PUMP: 14EW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES f DISPOSAL FLD�' PROP. LINES f FOUNDATION JD AGRICULTURE WELL OTHER WELL «� PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREACONS7RUCTION SPECIFICATIONS' `-_ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation Dia.'of Well Casing i Mbomestic/Private Gravel Pack ' © Tracy 9Type of�Casing ! Specifications i I'1 Public rf�-} Other 1:1 Delta __----Depth.of Grout Seal � Type�nf Grout I t Irrigation 2&Approx. Depth 1.1 Eastern �} Surface Seal Installed by ' Repair Work Done ❑ Type of Pump H.P. - State Work Done'— Well ane—Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow'50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPA'IRIA ON�1,J�DESTRUCTION I I (No septic system permitted if public sewer is { available within 200 feet.) C�, f ! Installation will serve: Residence Commercial_ `Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: * sem-zy' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ -.`off Method of Disposal Distance to nearest: Well Four dat06 _ t.-Propegy-,Line LEACHING LINE L1 No. & Lengfh of lines ` � � Total length/size FILTER BED .#. .�\`.❑- Dis[ance to-nearest: '}Weld t k da�tiont � t �'Property Line- .- `• ;# '"lY• ~' SEEPAGE PITS I 1 Depth f _ Size Number Y '� SUMPS L-1 Distance to,nearest: 'Well Foundation' ' Property Line;y (\( DISPOSAL PONDS ❑ { ' J I "\ I hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District -- Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work-for which this permit is issued, I shall not employ any person in such manner as to became subject to workman's compensation laws of Calif ornia.",'Contractor's hiring or sub-contracting signature certifies the following: '9 certify that in the performance of the work for which this permit is issued;,)shall employ persons subject to workman's compansa- tion laws of California." j The applicant m r a regwre ns. Complete drawing on revers sides-_�„�• !} - ' _Y,. � 12 Signed X � � itle: - � Date: FOR DEPARTMENT USE ONLY, a :Application Accepted by Date Area Pito Grout nspection by Date r final Inspection, y ? Dat Additional Comments:© `� �J'V1 u W .G/W;�i/ r Ai'+`e rrns , 3b/ jr s _Q-Stk+466-6781--�.-0 I i-359 3627°`-4 D-Manteca •823-7 04-—0 Tracy-.835-6W5 -----�- -- -'a i------� - Applicant - Return all copies to: Environmental Health-Permit/Services 1601 V. Vi zelton Ave, P:O-Bax 2009,-S1C CA�"95201 FEE . t - • CK' SSS. AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. fly, INFO- -^.^•_ M +.EH 13-241FtEv. EH t4-26r