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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL—i ON AU#., STOCKTON, CA ;f ephone (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. ,4 10 �1 p'�` ��/ of Size.�- �"�t PM Job Address ' k, ? ►�I�,: 3 ',' s jig �: ' _. {''` ., " r Owner's Name f�/9P/1—L =Address f Phone I ContractorR0 , ddre—ss 72ZZQ__! � License No. .---P'hone'Phone 'TYPE OF WELL/PUMP:i NEW W.ELL4WELL:REPLACEMENT ❑ DESTRUCTION ❑ PUMP.INSTALLATION _ SYSTEM REPAIR 7 OTHER._.... DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F} D. --' PROP. LINE, FOUNDATION ,AGRICULTURE_WELL OTHER WELLN^ tf�—_.. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATJONS /r 11 Industrial ❑ Open Bottom El Manteca i1'-'ba_of=Well Excavation` A!� o Dia. of W{ell Cappsing• 19 ,0Domestic/Private ;@jGravel Pack EI Tracy Type off C~asing ations 1 y .❑ Public ❑ Other ❑ Delta «Depth of Grout Seal w€ { Type of Grout �S ❑ Irrigation .. QApprox. Depth ❑ Eastern Surface Seal Installed by' `� I 6 Repair Work Done ❑ Type of Pump 50A H,P. State Work Dane f a Well Destruction ❑ Well Diameter . Sealing Material (top 501 Rte_ IN Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _Aa\t.avaAble within 200 feet.); R ' Installation will serve: Residence_ Commercial_ Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth !! Y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y �. PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation Property Line } ''t` {0 LEACHING LINE ❑ No. & Length of lines Total length/size �f FILTER BED LJ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS—F]---Depth size; ' ^l —Number " f SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 ofdinen`ces,'state laWs, and -i—^' rules and regulations of the San Joaquin Local"Health District. I b "ilii i 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 orisub-contracting signature certifies 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- tion laws of California." _ The applicant t call f all r u'red inspections, Complete drawing on reverse e. *� 4 /� ��_ f Signed X, 6z Title: Date- 'k FOR DEPARTMENT,USE ONLY —7 c Applioati n Accepted by " Date / J' " Area Pit or rou Inspection by ZDate� Final Inspection by Date / Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 .'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM&NO. w INFO CASH +EH 13-24(REV.1/85) EH W26ik O F