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APPLICATION FOR PERMIT cc,uM SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE.,,STOCKTON, CA 7 Telephone (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. pp Job Address _ 7 J �- Lot Size PM Owner's Name d1l e Address - 1- ,� ;. Phone Contractor� �� L � ' Address License No TYPE OF WELL/PUMP: NEW WELL ❑ Phone WELL REPLACEMENT Q � ,g DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM,.REPAIR O # DISTANCE TAEARE.0 SEPTIC TANK wL,4 yt'OTH�ER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE .,FOUNbATION AGRICULTURE WELL-. OTHER NVELL Y. } PITS/SUMPS INTENDED USE C �' f=� -� , $�. TYPE OF'1NELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial f V Open•Bottom Id Manteca Dias of Well Excavation- ~ ❑ Domestic/Private ❑fGravel P ck ❑ Tracy T Dia. of Well Casing ❑ Public Type of:'Casing -^^ Specifications C�`Other . <❑ Delta Depth of-Grout Seal ❑ Irriga`tion _--Approx. Depth/ ❑.,Eastern ` ' Type of Grout - Surface Seal Installed by Repair Work Done ❑ Type of Pump r j{ p F� Well Destruction '❑. Well Diameter r ' . State Work Done) SealingteriaL(top'50'► +. N r '"�� : FilleriM ial (Below 50') u Depth r"� r 3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR/ADDITION DESTRUCTIONINo septic system permitted if public sewer is available within 200 feet.) Esq Installation r will serve. Residence� Commercial, Other. Number of^living units Number of b oms l� 1 a ti Character of soil to a)depth of 3 feet: i .f - SEPTIC TANK —e Water table depth ❑ T /Mf ! Capacity PKG. TREATMENT PLT: No. Compartments f y Method of Disposal Distanceto,nearest: Weil t �� 1 - � 1 �fs tFoundation �� property Line F i12�x LEACHING LINE ).. ` ' ;�= No. & Length of Iineslt"� S - - ��•..M. FILTER BED ., - Total length/size C❑CDistance_to nearest: WP{�+ �'" ti j. t. �• undation��`�= Property Line [ ' SEEPAGE PITS ❑ -Depth• _._Size SUMPS ) kA. � 1 T 'Number X Distance to nearest Well=��_ Foundation. DISPOSAL PONDS ` E Property Line 1 hereby certify that I have prepared this application and that the w&rk�will'be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner.or licensed'agenYat s signure certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not + employ any erson in such manner as to become subject-to-workrnan'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 ,. ,' P Y Persons subject to workman's compensa- tion laws of,California."" applicant mwoballj for all required inspections. Complexe drawing on reverse side, Signed X k [ioTitle: /�J-�, Date: A FOR DEPARTMENT SE ONLY pplication Accepted by Date ,f Area Pit or Grout Inspection by /' Date 4_ 7 Final Inspection`by Date Additional Comments: 'f -5 F1Stk 466-6781 ❑ Lodi 36V3621f ❑ Man ace 823-7104 Tracy 835 6385 r Applicant- Return all copies to: Environmental Health Permit/Service4_1601_ azeltan_Ave..,_P..O._Bax 2(109,-Stk:;GA-95201 �-- x FEE A INFO MOUE UNT DAMOUNT REMITTED CK ' ^- CASH-k• *: ',RECENED BY '� DATE PERMIT NO. + EH 13-24(REV.ri8s) `A �Q — fl_. .y_ `:,� EH 1428 00r �' `^' — Q�-•-°'1`-'�