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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone f209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED I (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..)his application is made in compliance with San Joaduin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. j } Z ��I Job Address ! City Lot Size PM Owner's Name I� Address � "" Phone `T 77/ Contractor —Aga c� Address =EPL-A License No. l Phone TYPE OF WELL/PUMP: li, NEW WELL.lk "��t'* ;WEL'L� EIIAE�NT DESTRUCTION © t 1. PUMPi INSTALLATION " Com- SYSTEM PAIR ❑ OTHER ❑ I �_ � PROP. LINE -{?13ANCET_O-NEQREST�SEPT�C TANK _SEWER LINES DISPOSAL FLD. _ r ) l d-FOUfVDATION?'_ �l� AGRICULTURE WELL t'� OTHER WELL PITS/SUMPS . d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONNS 1-1 Industrial" © Open Bottom' ❑ Manteca Dia. of Well Excavation—/5 "f -- Dia" of Well Cas g Domestic!Private Gravel Pack. ❑ Tracy Type of Casing Specifications _. }1-1 Public n Oth, Fl Delta Depth of Grout Sea! Type of Grout pQ,-Irrigation .AIIf(fpprox F tthh_1.I Eastern `.� Surface Sea! Installed by. Repair Work,Done [7 Type df Pump �j�z` H.P:7 �� State Work Done .Il. [�,, Well Destruct n ❑ Well f]iamete, I� Sealing Material (top 50'1 "V ~t° Depihl� .nt � ��1• Filler Material (Be --- TYP OF SEP.TIC.WORK:.,14EI/J IN _71_TAL TION l 1 REPAIR/ADDITION,1'I .IDE$TRUCTION l I' INo septic system permitted if public sewer is t. Nil �t a > -} available within 200 feet.) -Installation1 will serve: Residence_^ �commerdial_ Other , � - Number of living units: Numb'erof;tredroa�tis� Character of sotl to a depth of3<feet: 1 _��' Water table depth t SEPTIC TANK 0 Type/Mfg � � t ��A Capacity � No. Compartments PKG. TREATMENT PLT" ❑ '- ""_tee+ � t Method of Disposal Distance to nearest: Well Foundation t — Property Line LEACHING LINE 0 No. & Length-of lines 'i dotal length/size �N ' FILTER BED ❑ .Distance to nearest:, Well Foundation} Property Line SEEPAGE PITS l 1 Delpih I Size -INumber�` I� SUMPS Ll Distance to nearest: Well Foundation T + 'i- Property Line 1 DISPOSAL PONDS 11 I� lI 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 Di'Wict. I. Home owner ar licensed agent'sistgnatufe certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not i 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-f611bwing:"I certify that in the performance of thework for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." IJ�. f The applicant all re ui. t tions. Comple`te.drawing d"n irevetr`e�'side. ASI/ Signed X� Title: / Date: 1 I�. FOR DEPARTMENT USE NLY i' oN,t, t Application Accepted by f ' Date ��' r Area Pit or Grout nspection Date .�' Final inspection by_Z1, Additional Comments: © Stk 466-6781 �LcdiJ369-3621 L] Manteca 823-7104 LJTracy 835-6385Applicant - Reiurn all coes toEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O:Box 2009, Stk., CA 95201 IIS FEECy INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVE&Y �7DATE PERMITII NfOr" /� CH 13-24 14-28(REV.i/N 5) L/ \ e J� �" r F OAR.'J . EH I