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;., APPLICATION FOR PERMIT js SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address J ,<O r 1.2 , City A OF1 Lot Size "* X zo PM Owner's Name ✓'4,ga s A ��Z�r Ifs I Address w r)' rt Phone -� { Contractor's Name ! License.No. � '` Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION IF I PUMP INSTALLATION ❑ T SYSTEM REPAIR ❑ ,. . . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom I-] MantecaDia. of Well Excavation Dia. of Well Casing El Domestic/Private ') Li Gravel Pack ❑ Tracy Type of Casings Specifications ❑ Public ° ❑ Other ❑ Delta Depth of Grout Seal ' Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ~" Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Cl Well Diameter Sealing Material (top 501_ { Depth tFiller 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:,Residen*e'-"'- Commercial— Other Number of living units: Number of bedrooms Character of soil to a de of3 fee"' Y Water table depth SEPTIC TANK ❑ Type/Mfg € ' Capacity ry r No. Compartments r PKG. TREATMENT PLT. ❑ f # _= � "V Method of Disposal Distance to nearest: Well #_k.-.: Foundation f• ` Property Line LEACHING LINE ❑ No, 11 Length of lines ` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line , ` 411--�. ,� ► SEEPAGE PITS ❑ Depth r 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 agents 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_"Contractors 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." I The applicant must call for all required inspections. Complete drawing on reverse side.49 ` I Signed _ 20944 � Title: te: 3 p , ,J Ink&P. M USE ONLY ! �� Application Accepted by Date . t` Area Pit or Grout Inspection by Date Final Inspection by Dat1—_, Ci►fuf Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Retur�sllco 'esto nviro�rrlgMill Hes Pe itServic 1601 E, Hazelton A e., P, , Box 2009, k., CA�,►A,, woo �y FEEWe" EAMOUN DU AMOUNT REM/ ED E IVED B AT PERMIT NO. �Q+, A' ,� INFO ASH , + EH 1324IREV.101831 EH 1426. i "