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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 SEG 2 1 1601 E. HAZEL I ON AVE., STOCKTON, CA • Telephone (209) 466-6781 r-N\JIRCVEryTAL HLALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FF-WIT/SlERVICES (Complete in Triplicate) App /or install the work herein .This cation is madlication is hereby e n compliance with Sanade othe Joaquin nJoaquin Local County Ordinance Noh.District49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the Sawn Joaquin Local Health District. Job Address L a N Q 0 N E R City__ R� Lot Size PM Owner's Name Address 11664 S. HWY 99 MAN.TFCAPhone Contractor�HFNN T NGS RROS- DR_LL J�ddress_ I.icense No. 2 9 0I 1 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LX DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK $5 SEWER LINES 851 + DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r' Dia. of Well Casing 11 ❑ Domestic/Private {Gravel Pack Tracy Type of Casing pvr Specifications _. LX Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout, `, [-,E N T_ ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ^ Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL 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 rules and regulations of the San Joaquin Local Health District. 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 must call for all required inspections. Complete drawing on r vers ode. J Q Signed itle Date: !/9`�T�1 —d FOR DEPARTM T USE ONLY f� Application Accepted by Date ` Area d–s— Pit or Grout Inspection by Date L00vi Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Jfl ❑ Manteca -7104 ❑ Tracy 83545 Applicant- Return all copies to: Environmental Health Permit/Services 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO $76 (/��+^, /Q/� CpASH+ E14 13-241REV.1/551 'yV 7O•. V V i7a EH 1428