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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 District. �h ry u� Job Address + 1 �� '� City I POA-) Lot Size PM j1 GAJ �..✓VV A AAA-- Address AA—Address _ 3-ig we :t city - TYPE OF WELL/PUMP: ,fie NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION ❑ y SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC,TANK - SEWER LINES w DISPOSAL FLD. PROP. LINE �. s r FOUNDATION„ -AG.RICU-LTURE WELL„ _OTHEFi,WELL_ -- _PITS /SUMPS �O c i;INTENDED USES TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial y ❑ Open Bottom ❑ Manteca _ Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack- ❑ Tracy Type of Casing 5"`i Specifications f"1 Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout _ I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by=- _ -r_ s Repair Work Done ❑ Type of Pump H.P, State Work Done._ Well Destruction LJ Well Diameter Sealing Material (top 50') k" { P i Depth) Filler Material (Below 50') ° TYPE OF SEPTIC.WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is f' E available within 200 feet.) ' Installation will serve: Residence j CommerclaN Other 1 ' Number of living units: Number of b rooms ' L Character of soil to a depth of 3 feet: �.W�/ Water table depth f SEPTIC TANK ❑ Type/Mfg pIxrRrS Capacity f 014 i No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: a Well__. Foundation ai .Property Line 'A . LEACHING LINE No. & Length of lines /O Totaltlength/site FILTER BED ❑ Distance to nearest: Well Foundation f P operty Line-_..._..�c._�-�r o 2 S�s f: SEEPAGE PITS I 1 Delpth _ Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 4 i I hereby certify that I have prepated 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- - , Home owner or licensed agent's signature certifies the following: 'T,certify that in the performance.of•the'""work for which this permit is issued, !shall not employ any person in such manner as become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that i .the performance of the work forwhli�h this permit is si sued, I shall employ persons subject to workman's compensa- tion laws of California." r—" t The applicant mu t call for all requir -inspections:-Complete drawing on reverse side. t I- f gSigned Xti -_. .:Title:[. [1JVQ�L" Date- 0 7)6-la R ate:OR DEPARTMENT USE ONLY Application Accepted by > � Date "u Area I Pit or Grout Inspection by �� Date Final Inspection by t DateY' Additional Comments: ❑ Stk 466-6781 ❑ Lod i�369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 } ,_.Applicant..--Return all copies to:,Environmental.Health Permit/Services 1601.-E-Hazelton-Ave:,P.O:=Box 2009; Stk: CA-9520i��- FEE AMOUNT DUE AMOUNT-REMITTEO,�. f�CASFi �RECEIVED BY .• DATE PERMIT'NO. INFO ��EIA 14-26 .-7 / /j ('` �J EH 13-241REV.tirt 5Y VaO� { � (�� y� ! �/ J ✓ Jt v ! '