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APPLICATION FOR PERMIT CJ SAN JOAQUIN LOCAL HEALTH DISTRICT 7 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) .i .3®ort Application is hereby made to the San Joaquin Local Health District for a permit to construct ad/or install the work herein described.This applica ion is .. OBS-- nmade 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. E14 T , �a Job Address . �� : 4N f� City Lot Size PM Owner's Name Address Phone Zf0 ContractorDnrnn/S_ Address License No.4-�1� .-...._. Phone TYPE OF WELL/PUMP: L NEW WEL �. , WELL REPLACEMENT ❑ DESTRUCTION ❑ � PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS uow T I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A71ndustrial LWOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Z i ._ LJ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ „I EEL, Specifications V ❑ Public ❑ 09"e, ❑ Delta Depth of Grout Seal ❑ Irrigatio-,- ,3�_A P Type of Grout 4,-,4 pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 108 H.P. _. State Work Done Well Destruction ❑ Well DlameiVf Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I 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! m Water table depth SEPTIC TANK---- =per-Type/Mfg Capacity No. Compartments " PKG. TREATMENT PLT. Method of Disposal k "Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.& Length-of lines"-"---�-�•--- + t' —Total length%siie"�' FILTER BED ❑ Distan a to nearest: Well Foundation Property Line r 1 SEEPAGE PITS ❑ De_pth �fl'_ Size -'""�"`Numbe� - SUMPS 11Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby�ce6ify 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 regulaiiorls of the San Joaquin Local Health District. ; J"��y1 11 A ' Home owner or licensed agent's signature certifies the following: "I ratify.that in the performande dff:the•work for which this permit is issued, I shall not ' -11 employ any person in such manner astto'"become subject;to workman=s compensation laws of Cafiforma," Confractor's hiring or subcontracting signature certifies the following: "I certify that in the'performance of'the work for whit "thls:permit'is issued,I'shall-employ 6erso s subjec to workman' comps s tion laws of California." + F� '` �.. ./ r`t e }+C, W r The applicant all inspections. Complete,drawing on reverse e. i Signed Title: � pate: 7 3r �— } OR.DEPARTMENT M SE ONLY Application Accepted byI r.4 Data Z S SA,%a } r Pit or ou Inspection by s Date 2--2 ''Final Inspection by f Date ' [ ` ff f h---_ .:-Additional Comments:_ ` J [3 Stk X466-6781 ' odix369-3Ujl' P'Manteca 823-7104 r--. ElTracy 835-6385 t Applicant- Return a c'pi to:-Envi>nmental Health Pe6it/Services-1601 E. Hazelton Ave., P.O. Box '-'Stk., CA-96201 FEEINFO ,AMOUNT DUE AMOUNT REMITTED t CK RECE IVEf] BY DATE PERMIT"NO, CASH r-' r , , + EH 13-24{REV.t/est �`-- [` j �,- �, r, .�/ i�•'_� EH 14-26 it Y-.........bN,r�.t