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�U ;off APPLICATION FOR PERMIT 41 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA TelephCne (209) 466-6781 'I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Corniilete 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 weil/pump and the Rules and Regulations of the San Joaquin Local Health Distric�t.t I rf � "� F itl 6 L� r .J w .-1J �Yi.c:� J i e„ �1.� PMS J Job Address � /! L ,o - Owner's Name*-'D��/ � _�. Address ' 40r9/<k��Phone r� SH r �f i Phone6 Contractor's Nam vJ +✓ �' License No TYPE OF WELL/PUMP: NEW'WELL J WELL REPLACEMENT ❑ '. ie -DESTRUCTION LJ PUMP INSTALLATION C SYSTEM REPAIR ❑ ' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK '� SEWER LINES _ DISPOSAL FLD. — PROP. LINE FOUNDATION ` — AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' O Industrial E] Open Bottoms r 0 Manteca Dia. of Well Excavation r — Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ' ) _ ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ` 3 Delta , Depth of Grout Seal Type of Grout ❑ irrigation --Approx. Depth ❑ EasternSurface Seal Installed by - Repair Work Done ❑ Type of Pump H. State Work Done - Material (top 50,f — Well Destruction L~ m - Well Diaeter _ ,Sealing, Material {Below 50') t' Depth ._ Eller TYPE OF SEPTIC WORK: NEW INSTALLATION, REPAIR/ADDITION U DESTRUCTION ❑ (No septic system permitted if public sewer is �.: within 200 feet.) Installation will serve: ,.available Residence Commercial ! Other __ \ `xL.t 1 i� bedrooms r Number of Irving units: Number of �^ -�... D Character of soil to a SEPTIC TANK depth of 3 feet: 4 __ Water table depth •'.O Type/Mfg; �� t>� `Capacity No. Compartments' �^+ . •' Method,of-Dis osal PKG. TREATMENT PLT. C1II A � I' _ /aa Foundation -Property Line Distance to nearest: Well _1AQ ,LEACHING LINE ` ' No. & Length of lines _ 'T�ota!Aength/size- U Distance --Well �49 Foundation Property Line14 FILTER BED to nearest: SEEPAGE PITS Depth�� Size 33� Number -- U YFoundation 149 �'_ Property Line SUMPS F_ Distance to nearest: Well Jt n!QPnCGI Prlydne, 7 I hereby certify that I have prepared this application and that the w} rk 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 certifies the following: 11'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_rtubject to workman's compensation laws of California." Contractors hiring or sub -contracting signature certifies the following: "I certify that in the ps' rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requy a inspections. Complete drawing on reverse side. Signed Title: —62 W IV Date:' A -1-712;e4 FOR DEPARTMENT USE ONLY Application Accepted by ��l Date J -Area —�— Pit or Grout inspection by TT�A--dLdditknal Comments: " -- �tk 466-6781 LJ Lodi 369-621 ❑ Manteca Ap licant - Return all copies to: Environmental Health Permit/ i r EH 1324 MEV. 10/0 EH 1429 Final Inspection by Date 7-A1l`_%A_ 823-'7104 ❑ Tracy 835.6385 Services 1601 E. Hazefton Ave., P,O. Box 2008, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTEDC SH RECEIVED BY DATE PERMIT NO.