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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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, Joh Address z` �z� ��F4✓� �'�� City Lot Size PM d/ rz v � 1 Kr Z�Z. �- .rr.N�Z Owner's Name Address Phone 7 I il�shF /�f� 2a/ Contractor a�t4��s Address f5� License No. 7 'f 3 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ "�."y' `�'_- y--- ....s.�.. t SYSTEM REPAIR❑' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP, LINE FOUNDATION,--- - � -AGRICUL--TYRE-WELL----�.__ -OTHER-WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open 80itom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy- --—Type-of Casing— j Specifications f/ f1 Public 1-1 Other Cl Delta, Depth of Grout Seal Type of Grout— I I Irrigation —.Approx. Depth ['I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump ! H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION f I (No septic system permitted if public sewer is < , available within 200 feet.) Installation will serve: Residence Commercial— Other •. Number of-living-units.' `1 Numher of bedrooms_..�_, Character of soil to a depth of 3 feet: I �� y Water table depth SEPTIC TANK �—Type/Mfg � C,05-7- e17,4,C', /ZO.O Capacity --') „No. Compartments PKG. TREATMENT PLT:❑ �� i Method of Disposal �f��rf . Distance to'Latest: Well � Foundation Property Line l0 t l LEACHING LINE lPr—No. & Length of lines 2 — `r Total length/size /70 `f FILTER BED ❑ Distance to nearest: Well �y9 Foundation_ lOf Property Line �� SEEPAGE PITS Depth Z Size__ 7� �r ^. r Number rZ, r SUMPS 0 Distance to nearest: Well �' — Foundation l-O'r' Property Line :0-- ! DISPOSAL PONDS .❑ I hereby certify that t 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 Diktrict. 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 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 tion laws of California." all em pto y persons subject to workman's compensa- } The applicant must cal all requi ed ins ctions.C pp et dra ng on reverse side. `k Signed X Title: Date: F DEPARTMENT USE ONLY Application Accepted by T "`" ° Date^ Area_ E Pit or Grout Inspection by Date Final Inspection by Additional Comments: r ❑ Stk 466-6781 0 Lodi 369-3621 Ll Manteca 823-7104 El Tracy 835 6385 Applicant - Return all copies to; Environmental Hearth PermitlServices.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E f FEE :AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY lDATE[� PERMIT'NO. ♦.EH 73-24(REV,t i n 51 EH 14-26