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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA a Telephone (209) 466-6781 i,PERMIT EXPIRES VYEAR FROM DATE ISSUED"'1 9b"tC (Complete in Triplicate) {, -14 =w. b 'r eV 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 t 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. w . �, ;r.t �. .. j•. .a � - �;.� A .. l , x . . : . • E Job Address L f 1" s1 CityL 'Lot'iizeIpry . I 1 0,;jo:014 '10 k( - ,.7Yq F - -;Owner's Name "°Address ��-- J. 1� ..Phone. Contractor Address License No. v�S�— ,3phoneq66`g� TYPE OF WELL/PUMP: NEW WELL ❑ k-WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ,i N y SYSTEM REPAIR ❑ OTHER ❑ i t.DISTANCE TO NEAR EST:,SEPTIC TANKSEWER LINES F i DISPOSAL FLD. . PROP. LINE «r " FOUNDATION AGRICULTURE WELL - '6THEllWELL PITS/SUMPS INTENDED USEj TYPE-OF-WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS �s ❑ Industrial ❑`Open Bottorn C] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pick ❑❑ Tracy Type of Casing Specifications ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout ❑ Irrigation -! }1 9 � 4 pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump jt.' H.P. State Work Done V3 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth . Filler Material {Below 50'} r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 'I. ;;F available within 200 feet.► Installation will serve: Residence X_ Commercial_ Other A I Number of living units: Numbelrof bedrooms ! 11 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mf 'I e Type/Mfg Capacity�� Q No. Compartments bL PKG. TREATMENT PLT. E] i Method of Disposal Distance to nearest: Weil Foundation Property Line LEACHING LINE No. & Length'of lines -T:;.l.:.w.,,_ '. l 9 � ` � �.. Total length/size F FILTER BED ❑ Distance to nearest: Well__./ f Foundation Property Line SEEPAGE PITS ❑ Dept + Size ber ' SUMPS istance to nearest Well ndation Property Lin DISPOSAL PO ElH hereby certify that I have prepared this application and that the work'will be done in accordance with San Joaquin county ordinances, state laims, and rules and regulations of the San Joaquin Local Health District.-j7cf I i Home owner or licensed agent's signature certifies the foilowing:, "I certify that in the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subjecf-&o Aiorkman's`cvmpensation 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 persons subject,to workman's compensa- tion laws of California." l 9 i Thea 4 € } pp' must call for all quit inspections. Complete drawing on erse side. � Signed ,. .� Title: Date FOR DEP TIM T USE ONLY ,` Application Accepted by 1�%✓! Date Area t Pit or Grout Inspection by s Date f Final Inspection by Date_1140 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 I Q Manteca 823-7104 ` ❑ Tracy 835-6385 `Applicant- Return all copies to:,Environmental Health,Perm(it/.Services}1601„E. Hazelton.Ave.,.P.O..Box 2009,+Stk., CA 95201 FEE AMOUNT.bUE AMOUNT REMITTEdd CK f INFO { CASH RECEIVED 8Y DATE.:. PERMIT'NO. + EH 13,241REV.iie5} ap 5 i / �i s EH 14-26, ` IZ- '�—9!;, `I�a i