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APPLICATION.,FOIR,,PERMIT . �v: . SAN JOAQUINA LOCA,L-'HEALTH DISTRICT 1601 E.-HAZELTON AVE._, STOCKTON, CA , Telephone (209) 466-67$1 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED_i, a� n{�^�`0-Z':..(Complete:in Triplicate).,,tl 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 , ," �. , sf .- :. v �?f Tlsl.i3jf1O(� ° ' 1 a+a�! ..4 F. ',7 Y IG ' -�-�-� Job Address �" _ " City Lot Size PM .. Owner's Name • `''a ddress ' -- I+i a.��' - — - -- - Phone„ t _ Contractor's Name do License No. —� �r Phone TYPE OF WELL/PUMP: f NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ 7 " "PUMP INSTALLATION t SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. •- PROP, LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA •. CONSTRUCTION SPECIFICATIONS Industrial a a. ❑ Open Bottom=; :❑ Manteca Dia. of Well Excavation 'Dia. of Well Casing`r ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing -Specifications ❑ Public r ❑ Other ❑ Delta Depth of Grout Seal Type of Grout t n ❑ Irrigation- --approx. Depth ❑ Eastern Surface Seal Installed by v11 'Repair Work Donee Type of Pump H.P. State Work Done `p! Well Destruction ❑ Well Diameter Sealing N1,5erial {top 501 *r Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic.system permitted if public sewer is } " T available within 200 feet.) Installation will serve: Residence_ Commercial_ Other } Number of living-units Number of bedrooms ( Character of soil to a depth of 3 feet:' Water table depth [[tl`W""' SEPTIC TANK 1❑ pType/Mfg Capacity No. Compartments PKG. TREATMENT PLT! ❑ ,' Method of Disposal "Distance to nearest: Well Foundation Property Line LEACHING LINE j❑ No. & Length of lines Total length/size FILTER BED # "t El Distance to neeresti ;Well` Foundation Property Line SEEPAGE PITS ; [7 Depth Size. Number ',SUMPS "" r -"' ❑ 'Distance to nearest:" Well - Foundation Property Line DISPOSAL PONDS_ ` ❑ t 7 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. _ - Home owner or Vicensed;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 r 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;"f i y f mor---• -� k_ "� •j• i `The'applican must or all re ire inspections. Complete drawing on verse side. " i Signed title l��t� ,� Date W ro s 1 FOR DEPARTMENT USE ONLY t 'Application Accepted by, Date Area Pit or Grout inspection by De Final inspection by Date `Additional Comments: l I # oe — �• i❑ Stk '46Cr6781-- w L•otli_.369-3621- 4••--•p Manteca 823-7104 ' h` racy 835-8385 Applicant- Return all copies to: Environmental Health Permit/Services 160ye.Ttazelton Ave. P.O. Box 2009,'Stk.; CA 951201 .b. FEE" CK Y v� m 1 INFO AMOUNT DUE - AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i+ EH 13-24(REV.10/83)