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'~APPLICATION FOR PERMITT SAN JOAO.UIN LOCAL HEALTH DISTRICT PCS VD � - I R 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ;`1}; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED III (Complete in Triplicate) �NVIRONM�NTAL HEALTH I9 akB W- iiVI�ES ,y kation is , Application-is h,e10y=made to-the San Joaquin Local Health,District for a permit to construct and/or install the work herein de pp made in compliance with San Joaquin County Ordmn'ance lVo +549 for sewage or No. 1862 far well/pump and the d Regulations of the San Joaquin Local Health bistnct .` R1 + ;. ZY1 `C l�—� ; CPS; ' C�rr� -rte Rd.- SOUth Side PM Job Address Crichett Rd 1 "pile°east of 'K city Lot sae 1� Owner's Name Ma Ile] Affiaral Address Phone Address P- License No.291M13 _Phone — Contractor Mei11115 Br05 DESTRUCTION ❑ ^ TYPE OF WELL/PUMP:" NEW WELL- WELL REPLACEMENT, ❑ �I SYSTEM REPAIR 13OTHER ❑ PUMP INSTALLATION C] DISTANCE TO NEAREST: SEPTIC TANK 170114 SEWER LINES! DISPOSAL FLD. PROP. LINE �. FOUNDATION, AGRICULTURE WELL _ OTHER-WELL t P{TSlSUMPS li IN USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C71 Industrial Y ❑ Open Bottom Ll Manteca Dia. of Wel! Excavaton ng H Dia. of Well Casirr i Type of Casin PVf Specifications Domestic/Private Gravel Pack Tracy yp g Type of Grout Ben.t011ite _. 1`1 Public (� Other Cl Delta ,,,, _ Depth of Grout Seal { 1 Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by driller _ H p State Work Done Repair Work Done 171 Type of Pump �— ` Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 I TYPE OF SEPTIC WORK: NEW INSTALLATION {'l REPAIR/ADDITION I I DESTRUCTION l l afvailable4wthin 200 feet't�ed if public sewer 1s € Installation will serve: Residence_ _ . Commercial Other f Number of living units: Number of bedrooms Character of soil to.a.depth's of 3 feet: Water table depth � �- SEPTIC TANK ❑ .;Type/Mfg Capacity No. Compartments Methodrof Disposal PKG. TREATMENT PLT., ❑,•2'. 'x " "t �t. i�Distance to nearest: . ,. Well Foundation Property Line � :I) 4 ! w ° Total length/size LEACHING LINE ❑ No. & Length of lines, FILTER BED ❑ Distance to nearest: Well Foundation ` Property,Line I i Il' SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Wel! Foundation Property Line f ==-:o.bISPOSAL—PONDS 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 g rules and regulations of the San Joaquin Local Health District. 1.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 t employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r 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 t� tion laws of California." "'The applicant must call for all required inspections. Co-rrjplete orqwing on reverse sick — Signed Henn i n S [Bros. by Date: O DEPARTMENT USE ONLY _ Application Accepted by Date Area l pate Final,Inspection by Data I Pit or Grou Inspection by Additional Comments: /J�6 ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Ma eca 823-7104 ❑ Tracy 835-6385 p Applicant- Return all copies)I to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201yo FEE CK RECEIVED BY DATE PERMIT NO. I FEE AMOUNT DUE AMOUNT REMITTED CASH7(\� y + EH13.24 IREV.5 i H 51 7aa.� , EH 14-2a LLL