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_ e � t ^ a APPLICATION FOF,i PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE_]STOCKTON, CA t iTelephone (209) 466-6781 :PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a (Complete in Triplicate) h District for a permit to construct andlof install the work herein described. This application is Application is heFeby made to the San Joaquin Local Healt made in compliance with San Joaquin County Ordinance No.549 for sewage or No; 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. �:�- 2�r ! L/P� City L.Dd' ' Lot Size ��/rP PM Job Address r /* „oP � OF �L�/PLr _ Address ,`. Phone Owner's Name G lLicense No Phone Contractor Address TYPE OF WELL/PUMP: t EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR El OTHER ❑ 77._ "� ..�`-PUMP INSTALLATION) '""""�""� DISTANCE TO NEAREST: SEPTIC TANK -Lg100 elf, SEWER LINES DISPOSAL FLD. PROP. LINE 1 t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r � Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well CasArlo}1. 9 - Specifications Domestic/Private I Gravel Pack LI Tracy Type of Casing (7� FI Public rf 1 Other F ❑ Delta Depth of,:Grout Seal O l Type of Grout�.[ F I I I Irrigation _Approx. Depth I Eastern Surface Seal Installed by ' H P I _ State Work Done Repair Work Done LJ Type of Pump Well Destruction ❑ Well Diameters Sealing Material Itop 501 Depth"" "r — 3.� - ..--=Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 RFPAIR./ADDITION I 1 Ii DESTRUCTION I I INo septic system permitted if public sewer is I available within 200 feet.) I � j Installation will serve-. Residence'- Commercial Other Number of living units: Number of bedrooms r Water table depth Character of soil to a;depth of 3 fee}:. - SEPTICTANKI ❑- Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t "`P Method of Disposal Distance,to near st: Well Foundation Property Line i Total length/size LEACHING LINE Ll` No. & Lersgth`bf iines� b�"T i FILTER BED ❑ Distanc9"to nearest:' Well Foundation Property Line 44 t F f SEEPAGE PITS l IDepth Size Number SUMPS -Cl -Dis : tance`to-nearest -# Well """"^'"'"Foundation Property'Lirie" """" DISPOSAL PONDS ❑ `` i 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 Dtiltrict. i 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 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: "1 certify that-in the performance of the work for which tfiis permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." , The applicant must ca r all r fired in c plate drawing on reverse side. Signed X Title: Date: I 9 FOR DEPARTM T USE ONLY F ' � - Area Application Accepted by �_ Date Pito rou nspectianrby Dae �FinlInspection by Data �. Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 "❑ Tracy '835-6385 Applicant Return all copies to: Environmental Health Permit/Sdrvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 41 FEE AMOUNT OUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24(REV.I/a N EH 14-28 ©� i