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- II yf PLICATION FOR PERMIT .E 7d pIOAQUIN LOCAL HEALTH DISTRICT I, _ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 9 YEAR FROM DATE ISSUED �r (Complete in Triplicate) I^ i lth District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaquin Local Hea 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. j L- �® CityLot Size PM I Job Address Owner's Name C UV'ey Address Phone Contraclar \A j 1�l t Address �S d License No. Phone S � - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LJOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTWER WELL PITS/SUMIPS i r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I L1Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing Specifications r1 El Domestic/Private - 1-1 Gravel Pack 171 Tracy Type of'Casing fl Public Cl Other Cl Delta Depth of Grout Seal ' Type of Gra Ikt I l Irrigation _.Approx. Depth I i Eastern Surface Seal Installed by k Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter _ Sealing Material atop 501 Depth Filter !Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION I 1 DESTRUCTION I o septic system permitted-if public sewer is available within 200 feet.) installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms ► i�, + Water table depth ! Character of soil to a depth of 3 feet: I SEPTIC TANK ❑"' Type/Mfg Capacity No. Compartments k PKG. TREATMENT FLT. ❑ „ c Method of Disposal E Distance to nearest: Well Foundation # Property Line ,E t �p l LEACHING LINE ❑�� No. & Length of lines Total length/size I FILTER BED s " ❑ Distance to nearest: Well Foundation f Property Line SEEPAGE PITS i^,.Depth ,' Size Number e II SUMPS Ll[I Distance to nearest: Well Foundation t Property Line E .l DISPOSAL PONDS .I 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 S ` rules and regulations of the-Sa"n Joaquin Local Health District. , f Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this pe6it is issued, I shall not ma employ any person in such nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature Pies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa ti n_la f Californi I' The applicant a I re u ed i a C m e drawing o averse s' e. II,�— z-+ -g t Title - -f Date: J Signed k _- FDR DEPARTMENT USE ONLY '� — DateAre Application Accepted by 2 _� 9 �C�I/_ _ .--Date 3.�- O �,Pit.o_Grout_Inspection_hy.� -Date _Final_Inspec6ori-by_p i Additional Comments: tp ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952011, / l CK RECEIVED BY DATE PERMIT'NO. FEE INFO AMOUNT DUE AMOUNT REMITTED CASH + EH 13-241REV.tin51 ��''� r EH 14-28 .i