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C - � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209? 466-6781 k i PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) 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. I i / aC.t� City r1 �.Lot Size. PM Job Address �+ f ;� !�q p Cl dl_ W /rte Address31 oZ ove, Phone ?� "`.' / f Owner's Name Contractor �? (110 Address92 License No. ? ` Phone NEW,WELL,�( W.ELL-REP-LACEMENT_V �,_QESTRUCTION P «•.-TYPE�OF.WELL/P.UMP:,, .......,.�..,.+ �--�-•-�--��- - t PUMP-INSTA LLATI4 3K SYSTEM REPAIR ❑ OTIJER 171 / """ pj57g1VCE 0 NE4FtEST'SEPTIC TAIVKT b SEWER LINES . 7 DISPOSAL FL U�' r rAGRICULTURE WELL - OTHER.WELL fb0! F' PITS/SUMPS <� FOUNDATION, k- iNTFNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f/ ❑ Industrial ❑ Open Bottom. Manteca Dia. of Well'.Excavati /r7 it Dia. of Well Casing I t` Type ` ' (- Specifications 6/9 SS I(r Domestic/Private )A Gravel Pack ❑ Tracy YP 9 _ f ❑ Delta Depth of Grout Seal c Type of Grouter - I"1 Public ppn ❑ Other 3 - I 1 Irrigation Ed^ 7*—, ApproxfDepth LSI Eastern SurfacAeal Installed by ' Repair Work Done ❑ Type of P 'State Work Done ump _:S�- _ `�.H.P. k � . Well Destruction ❑ Well Dia.,; r Sealing Material{top 50'I Depth ! ' A- � "_t i';Filler Material (Below�501 I TYPE OF SEPTIC WORK: NEW INSTALLATION -T—REPAIR/ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is available within 200 feet.l ' t s Installation will serve: Residence Commercial Other.717 11 — Number of living units: Number of bedrooms- t Character of soil to a depth of 3 feet Water table depth I m SEPTIC TANK ❑ TypelMfg w Capacity No. Compartments ti Method of Disposal PKG. TREATMENT PLT. El - .,,, . . a Distance to nearest Jt� Weil Foundation :Property Line F LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distanrce to nearest: Well �� Foundation Property Line SEEPAGE PITS I 1 Depth Size- ` ' � ' ¢ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ lication and that the-Work will be done in a�ordance With San Joaquin county ordinances, state laws, an I hereby certify that I have prepared this app rules and regulations of the San Joaquin Local Health District. k 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 empioy 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." k The applicant m st call for all required 1 spections. Complete drawing on reverse side. Signed X� l2-4 Title: ra__n 4�r?A�-401� Date: j FORD RTMENT I1SE'QNLY X Application Accepted by ® 1�`Y Date Area Pit or Grout Inspection by I Date 32 Final Inspection by Date ' l.�'p 114 e� Additional Comments: 4' El Stk 466-6781 -0 Lodi -3621 LI Manteca 823-7104, , ❑ Tracy 83 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f ` � FEE AMOUNT DUE AMOUNT REMITTED CK 4 SH RECEIVED BY DATE PERMIT NO. L INFO 6 �8-1053 .+ EH 13.24(REV.)/"5) r EH 14-2e