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# i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E: HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w. ' ,J. (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.; 00, Job Address sk.,l J� " ` City.oe�M— Lot Size pl( Owner's Name ddress j+1 ._Qt Phone Contractor Adaress icense No.ac M Phone TYPE OF WELL/PUMP: Z NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ x OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -L Industrial- r ,❑ Open-Bottom. ❑.Manteca,...-,,,.—Dia. Well-Excavation Dia-of-Weil-Casing-� , ❑ Domestic/Private ❑ Gravel Pack C. Tracy Type of Casing Specifications j ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout a Ll Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth �Filler,Material (Below,501) F TYPE OF SEPTIC WORK:a NEW INSTALLATION ❑_„_REPAIR/.ADDITION --DESTRUCTION 0-(No-septic-system permitted if public sewer is 1 available within 200 feet.) I Installation will serve: Resid rice� Commercial Other Number of living units: Nuifiber of bedroo s r 1 Character of soil to a depth of 3 feet: s r Water table depth h SEPTIC TANK ❑ Type/ �` ' "' 1 YP g• == -LCapacity- == = No-Compartments s PKG. TREATMENT PLT. ❑ ...+� Method of Disposal i s Distance to nearest: Well Foundation Property Line LEACHING LINE"- -No. & Length of lines Total length/sizet FILTER BED C1Distance to nearest: Well r Foundation �i� -�� Property Line_._-yZtf , SEEPAGE PITS Depth f -S ize r /�� Number : " V.x SUMPS ❑ Distance to nearest: Well g-6" Foundation _ Property Line DISPOSAL PONDS, ❑ - r k 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 rules and regulations of the San Joaquin Local Health District. ! 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 subiect to workman's compensation laws of California."Contractor's hiring-or sub-contracting signature i 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 Califo'rnia." ` , The applicant,rru'st call for all r wire�inspe ions Complete drawing on reverse side. + ,. F -. Signed r Title: `` Date: FO DEPART ENT USE ONLY (Odditional ation Accepted by Date Ar v4- ) S Grout Inspection by Da e' Final Inspection by D�ate— t _ rte '+� Comments:. I ❑ Stk 466-6781 - ❑ Lodi 369-3511 ❑ Mantua a B23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Heafth Per Ain Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' t _ y f TEFF AMOUNT"I)UE ""' '`"AMOUNT REMITTED` K Rtt&EE)0y ERMIT'NO. . . li INFO C �OATE P + EH 13-241REV.1/eto - - -EH 14-29 v / O i c7o �. I�� 5%L, i