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,4 + APPLICATION FOR PERMIT _ y SAN JOAQUIN LOCAL HEALTH DISTRICT �l1641 E. HAZEL T ON AVE., STOCKTON, CA ky Telephone (249) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '(Complete in Triplicate) m ; 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 t 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. k Job Address _ City Lot Size PM I ) i� r/ -.: - Address Phone -Owner's Name � , ' � - I � A Contractor/f'�r7e � � ' Address— t� 2� � � License No. Phone TYPE OF WELL/PUMP: NEW WELL-❑ WELL-REPLACEMENT E3DESTRUCTION [3 Y PUMP INSTALLATION' �., �% SYSTEM REPAIR "❑ OTHER LJ � DIS ANCE TO NEAREST: SEPTIC TANK �' SEWER LINES,`` DISPOSAL FLD. PROP. LINE E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS] INTENDED USEPF OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k r C1Industrial ❑ Open Bottom. " ElManteca J/�fi 'Dik of Well Excavation Dia. of Well Cas ng it �- Specifications €' ❑ Domestic I Private ❑ Gravel Pack } 3' racy -Type of Casing r ❑ Public ❑ Other ❑ Delta` - Depth of Grout Seal Type of Gro t } f:. ❑ Irrigation --Approx. Depth ❑ Eastern .P,Aj SumSegl Installed by Repair Work Done ❑ Type of Pump } H=P• _ �'t"`�Stte Work Done 1 Well Destruction ❑ Well Diameter{ J Sealing=Materialatop 50'} Depth Filler Material (Below 50'f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (No septic system permitted if pubicT"§Dwer-4, I E available within 200 feet.) Installation will serve: Residence Commercials Other + Number of living units: Number of bedroomss�� Character of soil to a depth of 3 feet; ((( Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity { ' No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal Distance to nearest: Well Foundation Property Line r I LEACHING LINE No. & Length of lines �- ^�� -ITotal length/size r FILTER BED ❑ Distance to.nearest: Wel �Foundation Property� P rty Line � r SEEPAGE PITS ❑ Depth " Size - ? Number �h ' 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. i I ' 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 j laws of California." f ;� The applicant must ca or all requ' dins ns. Complete drawing on reverse side. I A r Signed Title: Dater I . FOR DEPART USE ONLY Ip I [ j A Area Application Accepted by date ,�4 Pit or Grout Ins'��'//ee__cfon by4'—'!.7!� Date Final Inspection by IJ+Y�+�i� "-f"='I Date 3l1��0- Additional Comi!neTTTLLL111ts: �� « �✓ S a `�' `�P Ik r __❑-Stk-^"466-6781 .. ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy' ' � --- �i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE � INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY r DATE PERMIT'NO. '+ EH 18-24(REV.t/95) Q f� - 1 �-- EH 14-28 r