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f - APPLICATION FOFi PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL.T ON AVE.,:STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED 4, _ P (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.549for sewage or No-. 1862 for well/pump and'the'Rules and Regulations of the San Joaquin Local Health District. 1PN D � � Y O Q PM Jab Address City tot Size r-, *%. e ddress " Oa3 i - Phone V6 2-:Q/ Owner's Nam "iQ ContractoJ r Address / _ _- License No.7 SOPhone • y "�� A TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION r li PUMP INSTALLATION 71 SYSTEM REPAIR E3 OTHER L;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 `431•Industrial I 0 Open Bottggn_E7_Manteca,. ___._Dia. of Well Excavation Dia. of Well.Casi ng y F1Dom stictPrivate ElGravel Pack ❑ Tracy Type of Casing Specifications f ' [:_F.6 Public O Other ' . ❑ Delta Depth of Grout Seal �_„ Type of Grout ` f � t rox. Depth '❑ Eastern Surface Seal Installed by ❑ Irrigation' app p s r» i Repair Work D06e\ ❑_Type of Pump% H.P. State Work Done Well.De uction x Y❑ Vileh Diameter^ `< Sealing Mateiial (top 50') _ 114 Depth Filler Material{(Below 50') 1, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ESTRUCTI N ❑ JNo septic system permitted if public sewer is i agailable within 200'1eet.l I installation,will serve: Residence Commercial Other l Number o61ving units: Number-of bedrooms �^ Character of soil to a depth of 3 feet: I /.� Water table depth ❑ Type/Mfg Capacity _.-_ No. Compartments SEPTIC TANk PKG.-TREATMENT-PLT. © s Method of Disposal F$ Distatq nce to nearest: Well - Foundation _ Property Lme It LEACHING LINE +❑- No & Lengs th of liner 9" , /size r- Total`len th FILTER BED ❑ Drstance_t nearest: Weil Foundation .��ft Property-Line 1 SEEPAGE PITS � ' -a' I]eptYf- Size I Number I tV:;- �, S MPS ❑" Distance'to nearest: Well Foundation ""�Propeity Lined Z U DISPOSAL PONDS ❑' w ' P T"f --t� 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 perforinance of the work for which this permit is issued, I shall not employ an erson in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature p Y of certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workmari"s compensa- tion laws of California." j` # The applica must carr all required inspections. Complete drawing on reverse side. F F E ^' =rs Title: Date: _ Signed j Crr OR DEPARTMENT USE ONLY t� I Application Accepted by Date — L"v� Area 1 7( Pit or Grout Inspection by! Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑Lodi 369-3621 ji.❑ Manteca 823-7104 ❑ Tracy 835-6385 `Q L Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, Stk., CA 95201v°' i . IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY y DATE PERMIT'NO. } . v - f + EH13-24IREV.t/nal �- x;7" Q EH 44-28