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Ii ab APPLICA BION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELT ON AVE., STOCKTON, CA ii Telephone (209) 466-6781 PERMIT EXPIRES 1-IYEAR FROM DATE ISSUED (Complete in Triplicate). IIiication is Application is hereby made to the, San Joaquin Local Health District for a permit to construct and/or install the work herein described. the pp made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations off the e San Joaquin Local Health District.. PM city o Job Address —lL City�� f Size — �' p� Address + Phone Owner's Name �"'� ContractotW" `" �' _ ddress " -'---J'" License No_5�� — Phoneme. _ TYPE OF WELL/PUMP:.- lj. NEW MILL.O WELL REPLACEMENT LJ DESTRUCTION G r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ✓� �� e k OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES DISPOSAL FLDPROP,. LINE `_PITS/SUMPS.._ FO.UNDATION;__AGRICULTIURE WELL . '' OTHER WELL _ INTENDED USE TYPE OF WELL PROBLEM AREA '� CONSTRUCTION SPECIFICATIONS ❑ Industrial .0 Open Bottom G Manteca Dia. of Well Excavation _..__ _. Dia. of Well 1. Casing f _ t^ f » s I % �' `° Specifications ❑ Domestic/ Private d Gravel Pack 0 Tracy -Type of Casing - Pe 1 'F1 Other Cl Delta Depth of Grout-Seal_^•Z-% `J'A �" ' - Type of Graui�! M'Public .. I'A rox_D•e th I I Eastern, Surface Seat Installed by - - I Irrigation —� Pi>� P. . - - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil. Diameter Sealing Material Itop 501 t_ :• � - - tt -- Depth _._ r Material (Below s - TYPE OF SEPTIC WORK: NEW INSTAL 4ATI0 EWR/ADDITION DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence A�__. Commercial _ Other_ Number of living units: Number'of bedrooms Character of soil to a depth of 3 feet: Water .tabte depth r + T pi 0 No.. Compartments SEPTIC TANK Cl Type/Mfg,. �� .. Capacit Method of Disposal f - 'kms PKG. TREATMENT PLT. El yl r, f, Distance to nearest: Wells 6 Foundation�p., _ �! Property Line D LEACHING LINE X. -No. & Length of lines - ' � dr --� - -:"'•-"Tata) length/size FILTER BED n Distance to nearest: Well; Foundation `� �~ 1 Property Liner.Tr ^� /-� Number= SEEPAGE PITS Depth _1:2 5: Size _=t -- _ SUMPS 1 U Distance to nearest: Well J� b Foundation SCC L'_ Propertyy�ine--1 ? i DISPOSAL PONDS L 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. 11 t Home owner or licensed agent's signature certifies the following: "),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 permit is issued, I shall employ persons subject to workman's compensa tion laws of California." 'i � i The applicant mu{' ca fIf or all r ired inspections. Complete drawling .on reverse side. ,. - a Signed X- =Title: -1 Oat I FOR DEPARTMENT USE ONLY 0 - Application Accepted by - P Date _ .Area Pit or Grout'[ nspection . Date Final inspection by —Date Additional Comments: 4- _7Y.-� El Stk 466-6761 ❑-Lodi._3697.3621. .. O-Menteca;*kI Applicant - Return all copies to: Environmental Health Permit/ a EH 132+1(REV. r/KSI EH 14-2e ---�-Tracy-835=6385 1601 E. Hazelton,A`ve., P.O. Box 2009, Stk_, CA 95201 1 7-