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APPLICATION FOR PERMIT SAN JOAQUIN LOCA HEALTH DISTRICT HZ 1601 E. EL T ON,► E., 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. , 4Job Address City of Size PM Owner's Name T� t 1 r 1A t t AddressPhonq3J.z%Se Contractor Address Licefise No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI,ON ❑ PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ OTEIi"❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. r DISPOSAL FLO. PIOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL SI 'WELL OTHER ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '� I Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sealer I Type of Grout "� 0 ❑ Irrigation ---�Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump._ H.P. Stale Work Done # Well Destruction ❑ Well Diameter Sealing Material (top 50'1 J Depth I Filler Material iBelow 501 1 % +r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I"� 1IF t available within 200 feet.) ` Installation will serve- Residence Commercial_ Other 1 t I Number of living nits: dumber of bedrooms vr-y Character Of soil to a depth of 3 feet: 4403 Water-table depth r� SEPTIC TANK Type/Mf g Capacity MOO, No. Compartrgents � PKG. TREATMENT PLT. ❑ ; _ T t � Method of Disposal �= "su t Distance to nearest: ell\CL7j.�,_'__._. Foundation Property Line= tiIt LEACHING LINE No. & Leng of lines � ! t �. Tota length/size FILTER BED LJ Distance t nearest: Well Foundation' - All Property Line !�2 s �r i :. ! I = 4f I SEEPAGEITS ; Depth t Size �3 {� �"r Number s 1 SUMPS 1:1 Distance to nest: Well\dt]4 Foundati n ! Property Line DISPOSAL IPI ❑ ! I I ! I hereby certify tAat I have prepared this application and..that the work will be done in accordance with Sin Joaquin county ordinances, state laws, and rules and regulations of the.San Joaquin Local Health District. 3 k Home owner or licensed agent's signature certifies the follbWing:�l certify that in the performanoe'of the work for which this permit is issued, I shall not employ any person in such manner as to become subject workman's.compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that iri the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant m t call for all required inspections:-Complete drawing on reverse side. Signed 1111 IiA + Title: ! t Date: ~ FOR DEPARTMENT USE ONLYY11 11 i Application Accepted bAL6,Ndl' - Date Area Pit or Grout Inspection `Date�� 1 Final Inspection by Date Additional Comments: `�/ l T'r j' T R n � a Stk 466 fi781 62Fil : t❑ Manteca 823-7104 ..� ❑ Tracy i (� 0 GI Ui/, q(y Applicant-Return all copies to: Environmental Health Permit/Servi�as 161 E. Hazelton Ave., P.O. Box 2009, 5t ., CA 95201 el FEE INFO AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY I DATE PERMIT NO. + EH14-428 26 EH, EV.I/a5) /