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�F 3: I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ii Telephone (249) 466-6781 �F 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 Distr"7 Z ,�j 4;r kc � r !`` i Job Address ity Lot Size PM I Owner's Name Address Phone ' " 3Phone Tim Q Contractor's Name _— License No. " ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE € it FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �l I�INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑,Industrial ❑,Openl Bottom ❑ Manteca Dia. of Well Excavation i;` Dia. of Well Casing �} ❑.Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications rv1' l i ❑i Public -----Q-Other--- - --�O-Delta...-+. Depth of Grout Seal Type of Grout Ll Irrigation ---Approx. Deit pth ❑ Eastern Surface Seal Installed by r ,;, 1; H.p. State Work Done Repair Work Done El Type of Pump W �} ! Well Destruction ❑ Well Diameter Sealing Material (top 50`) t? 1 QIP } Depth ;I; '"` , t ,> Filler Material (Below 501 �= TYfpPE OF SEPTIC WORK: NEW INSTALLATION `REPAIR ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet.} IEnstallation will serve: Residence� Comrriercial� — Other�R&D �� i Number of living units: i Number of bedr ms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity �Q— No. Compartments 3 PICG. TREATMENT PLT. ❑ ;1 Method Of Disp os_al O>V G i, � ! -t Srfu� o�l TR�p il/Distance to nearest: Weil e� Foundation �' Property Line _.- ?. .r LEACHING LINE ElNo.';& Length of lines Total length/size ~ FILTER BED ❑—Distance to'nerr6st:'--Well-` Foundation Property Line SEEPAGE PITS LIDepth Size fNumb,, SUMPS ❑ Distance to nearest: Well Foundation f Property Line RISPOSAL PONDS ❑ I IIhereby 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. �.1 F. is Y ;} • r } Home owner or licensed agent's signature certifies the following: "I certify that in the performance df the work for.which this permit is issued,,, shall not € employ any person in such manner as to become subject to workman's compensation laws o#;California.'�Confractor s hiring or sub contracting signature i certifies the following:"I certify that in the performance of the work for which this permit is issued,I'shailfemploy persons subject to workman's compensa•-- tion laws of California." j, p .he applicant W. call for all eq�uir spections. Complete drawing on reverse side. u hh I Date: 7 G Title: t s Signed F0eD&FFAR T USE ONLY i Application Accepted by Date a Z Area s-aa&s Pit or Grout or !�' Date Final Inspection'by Data 01 Z. Z-nW-7A Additional Comments: ❑ Stk 466-6781 ❑ Lodi !369-3621 ❑ Manteca 823- .104 ^ Tracy,*'835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1'601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 A t FEE AMOUNTDUE AMOUNT REMITTED T �ASHa RECEIVED By_ —DATE,- PERMIT;.N0--,:' fk -INFO- - — `, + EH13.24(AZ F EH 7428 'Q