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a -� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� 1601 E. HAZELTON AVE., STOCKTON, CA .t Telephone (209) 466-6781 Ile C, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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 Job Address rA��_.___ - �L �/ �l City��.;5� cvle PM Owner's Name �� Address Contractor CALk0gZ!5. eD L//A1Address Phvn TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1170 SEWER LINES DISPOSAL FLD. PROP. LINE "^~ FOUNDATION,. AGRICULTURE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATQONS , ❑ Industrial ❑ Open Bottom :❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 11kms{"ravel Pack ❑ Tracy Type of Casing f Specifications F1 Public CI Other -w Depth of Grout Seal Type of Grout 6 ud ! I Irrigation VApprox. Depth l I Eastern Surface Seal Instalold Repair Work Done IF, Type of Pump — _ H.P. State W Done_ CIO Well Destruction V9— Well DiameterSealing Material )top 50') Depth,-20 1-- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I], REPAIR lADDITION-1-1,. DFSTR TI l I Wo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence= Commercial_ Other i Number of living units: Number of bedroorms• Character of soil to a'depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _- � `Capacity No. Compartments a PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation } Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE E GE PITS I 1 Depth Size _ Number � t � r SUMPS L-f Distance to nearest:' Well Foundation Property Line ' DISPOSAL PONDS ❑ Y . 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 Home owner or licensed agent's signature certifies the following: "I certify that in the.perfortnance 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 taws 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;l shall employ persons subject to workman's compensa- tion laws of California." The applica t t f ,all req ted ins ctions. Complete drawing on rse side. V -------"-- i. Signed X Title Date:` �r} a FOR DEPARTMENT USE/NLY rt', Application Accepted by13 !d(�•�'J/� Date��7 -` Area Pit or Grout Inspection by Date Final Inspection by Date r' Additional Comments:. //L/ J wig: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _,- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE _ +.EH1ti 21IREV. h51 p [I� EH 144-2e