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APPLICATION FOR PERMIT { SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781: PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) cribe . This cation is lor install the work Application is heieby with ma SannJoaqu nn County OrdinaJoaquin Localncle Nto.549 for sewage ealh District for a or INo.1662 fort to cwellldpump and the Rut s and hereinR gulations of the Sant Joaquin made in compliance Local Health District. 1 �} r. �- 1 Cit Lot Size\ J _ PM Job Address k� O r� �7 'f 4 , , Rhone ` Owner's Name (os- 11's Address A�W ! License No. ��2� Phone3 .�Ts[a s— PO A • r Contract r,441 Address NEW WELL ❑ -WELL REPLACEMENT ❑ DESTRUCTION 0 TYPE OF WELL/PUMP: HE ❑* rr ` -PUMP-INSTALLATION D. ,�..: SYSTEM REPAIR,.❑- _-..._OT R ,��, �^ DISTANCE TO_NEAREST: .SEPT.IC�TANK�,-- Y — S,EWER-:LINESDISPQSAL ''AGRICULTURE WE OTHEfl WELL PITS/SUMPS ' FOUNDATION i� —INTENDED�rINTENDED USES`""'"TYPE-OF-WEtt:-- 'PfiO EMAREA CONSTRUCTION-SPECIFICATIONS�-'� ' '4: Manr taco Dia. of Well Excavation Dia: of Well Casing 0 Industrial; ❑ Open Bottomre` 1 r "• '=�-- Specifications 1 Type_of-.Casing " , L) Domestic/Private ❑"Gravel Pack _ E: Tracy` - I"1 Public ❑ Other k r C1 Delta + Depth of Grout'Sear °'"` ' -Type of Grout— ['I I I Irrigation' .Appiox: depth 1•1 Eastern Surface Seal Installed by ^�' _� State Work Dnne� t Repair Work Done ❑ Type of�ump H-P• n rk Well Destruction ❑ Well_Diameter Sealing M terial Itop-50'"1-===77 "r Depth Filler Material IBalow 501 j TYPE OF SEPTIC'WORK: NEW 1NS,TALLATION [V-REPAIR/ADDITION l l DESTRUCTION l 1 INo septic system permitted if public sewer is 1 a available within 200 feet) installation will serve: Re/sid, Wde Commercial. Number of living units: •4! Number o " d m I\ 00 Character of soil to a depth of,3-feet`" y , *� -1Nater table depth 'Capacity-, a__.Q 'No. Compartments SEPTIC TANK �"G� Type/Mfg PKC. TREATMENT PLT. ❑ T /' 1<.,! Method of Disasal I A D_ Foundation-� -- Property Line Distance to nearest: / Well f V(-"N.. /Y x LEACHING LINE Y(' .No. &,Lengfh of lines To length/size -" Property Line FILTER BED ❑ Distance to nearest: Well ac) — Foundation_ t SEEPAGE PITS ~r I, Depth Size 3 Number SUMPS Ll Distance to nearest: WeN Q�% Foundation "Property Line � DISPOSAL PONDS ❑ applif cation and that the work will be done in accordance with San Joaquin.county ordinances, state laws, and l hereby certify that I have prepared this rules and regulations of the San Joaquin Local Health District. .J 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 or sub-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 m all for al quir inspections. Complete drawing on reversQ e. Signed X Ilk Title: tM/1 Date: FOR DEP RTMENT USE ONLY Date Area L t Application Accepted by _ '= Date i Pito r Grout Inspection by Date /" Final Inspection v I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Trac y' 835 6385 Applicant . Return all copies to: Environmental Health Permit/Services-1 601 E. Hazel ton iAve., P.O. Box 20W, Stk., CA 95201 FEE AMOUNT DUE AMOU REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO F + EH 1324(REV.I/H 5) EH 14-26