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APPLICATIONkFOR PERMIT ' SAN JOAQUIR- .0CAL HEALTH DISTRICT 1601 E.:HAZEL T ON AVF., STOCKTON, CA Telephone (209)'46&6*' PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED (Corn fete i, Tri licate)x-^Bu t01tt1t L. "•.',;. i,, r{, ..; .`��:t:}fit-.^W .s.F u P. P, 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 wen/pump—.and the Rules and Regulations of the San Joaquin Local Health District -J-3 , PM _ City of Size Job Address k _ Address _ Phone - Owner's Name T ddress r License No. 2- Phone Contractor's Nam TYPE OF WELL/ P: NEW WELL 0 4 WELL REPLACEMENT ❑. DESTRUCTION ❑ PUMP INSTALLATION ❑ E. SYSTEM REPAIR ❑ 7 OTHER fl FDISPOSAL FLD. PROP. LINE 4. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "- - A OTHER PITS/SUMPS FOUNDATION AGRICULTURE WELL.'" WELL INTENDED USE TYPE OF WELL. PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS . _` Dia.-of Well Casing ❑ Industrial ❑`Open Bottom k ❑ Manteca Dia.;of We11_Excavation ` A. Specifications fl Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing. i t - � T e'of Grout ❑ Public ❑ Other -❑ Delta Depth of Grout Seal Yp Depth . 0 Eastern Surface Seal Installed by - ❑ Irrigation ---Approx. p State Work Done ...Repair Work}Done ❑.; Type.of Pump, �. _ Well Destruction ❑ Well Diameter m Sealing Material (top 501 i Depth - = Filler Material (Belovv 501 TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION' (No septic hstem rmiitted if public sewer is nstallation will serve: Residence Commercial_ Other ..ia.. a i Number of living units: Number of bedrooms 41 .. Water table depth Character of soil to a depth of 3 feet: c✓ Capacity No, Compartments SEPTIC TANK El Type/Mfg. PKG. TREATMENT PLT. El of Disposal. Distance to nearest: Well k Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: 'Well .. Foundation Property Line SEEPAGE PITS ❑ 'Depth 'Size — Number SUMPS L) Distance to nearest: Well Foundation __.Lt - Property Line DISPOSAL PONDS ❑ l hereby certify that I have prepared#fits 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. x' l' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt 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 folio g:"1 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 C rf nia." -' The applica II for all rg it pections. Complefe drawing on reverse side. y 571Title: �'� t"' Date: 10 Si ? FOR DEPARTMENT USE ONLY Dater.� ! r a Application Accepted by _ 71— Date Pit or Grout Inspection by f T Date 4 Final inspection by Acldilonal Comments: +. # - � � tk 466-6781 ❑ Lodi 369-3621 0 Manteca 823 7104'- ❑,Tracy° 83x6385 - f 601 E. Hazelton Ave., P.O. Box 2009 `Stk., CA 952fl1 App ant Return all copies to: Environmental Health Permit/Services 1 , + ' I " FEE 'AMOUNT DUE AMOUNT REMITTED C S RECEIVED BY DATE PERMIT"N0. INFOwr}/1. n _g, I Q(� G7� + EH 13-24IREV.10,831. VC`! EH W20