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APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL' HEALTH DISTRICT 1601 E. HAZE i ON AVE.,. STOCKTON, CA i Telephone (209) 466-6781 tPERMIT EXPIRES 1 YEAR.FROM DATE ISSUED r (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. Job Address S_sm� �rw, . . C. >!lYLf --� Lot Size - PM eww Owner's Name �_'_ .. Address A 3 L1A)_ Film cPhone ,�?_lk Contract1 7u� _ W—Address �u License No _ Phoneti„L_- TYPE OF WELL/PUMP: NEW WELL l WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. _ PROP. LINE FOUNDATION AGRICULTURE WELL _- -_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia_ of Well Excavation Dia. of Well Casing J Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications ❑ Public ❑ Other ❑ Deka Depth of Grout Seal Type of Grout LJ Irrigation —Approx. Depth ❑ 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') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ftEPA _ /ADDITION 9 DESTRUCTION L (No septic system permitted if public sewer is V ` i I- available within 200 feet.) a j Installation will serve: Residence /` Comtmrcial,_ Number of living units:_� Number ofrooms r A Character of soil to a depth of 3 feet: . �� ,�.�, Water cable depth �� SEPTIC TANK Type/Mfg K r J4 Capacity_L.571�-_ No. Compartments PKG. TREATMENT PLT. O ;I l t Method of Disposal 41 ` _ f Distance.to nearest: Well Foundation�� Property Line v' LEACHING LINE *No:�& LengtFi of lines _ Total length/size 0, 9 FILTER BED 0 Distance� 'Well r Foundation _ rProperty Line. , SEEPAGE PITS ID—Depth N Number SUMPS ] Distance to nearest;.,It.. Wet, Foundation �' _ Property'-Line DISPOSAL PONDS ❑ rv``'t w' V. 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 certif eii t e followi g rig:, 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 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 pemr it is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call'for all r quir inspections. Complete drawing on reversue -t Signed X Title: _ �f. - Date: * FOR DEPARTMENT USE ONLY / A Application Accepted by Date- `� r�O Cp -Area_ //2, � Pit or Grout Inspection by DateCC — Finaldnspection'by Date Additional Comments; ❑ Sik 486 6781 — '❑ Lodi 369-3621 ❑ Manta 923 7104 n Tracy 83 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO CASH +EH 13-241REV.1/a=_) - - - '• \ ' EH 14-26 ♦ �� 1� gb 8� �'7 .