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Iv .I :i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Ii 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209F466-6781 ii 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. r Job Address City Lot Size PM 1 Phone Owner's Name Address II: _ c �� Esc- Address b l0 r4 �- �3��License No. bY Phonemet � Contractor -�-� TYPE OF WELL/PUMP: NEW WELL ❑'" ' WELL REPLAGEMENT ❑ DESTRUCTION ❑ 4 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPITIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom Manteca,Manteca Dia. of Well Excavation Dia. of Wel! Casing Domestic/Private ❑ Gravel Pack- -.�TD Tracy Type of CasingSpecifications l'I Public n Other i l Delta Depth of Grout-Seal- - Type of Grout __ I I I Irrigation _!!Approx. Depth f I Eastern Surface Seal Installed by - 1 Repair Work Done L& Type of Pump °' H.P. 6 State Work one I Well Destruction ElWel!',Diameter Sealing Material (top 50') Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is II available within 200 feet.) installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms * Character of soil to a depth of 3 feet _ Water table depth SEPTIC TANK ❑ Type/MfgCapacity �•No. Compartments 43 PKG. TREATMENT PLT. ❑ I . ti ''.~ Method of Disposal 1 distance to nearest: +% Well -Foundation Properly-Line C) t � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ( I Depth Size Number i SUMPS Ll 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 Di"strict. ! 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 hcertifies 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." The applicant mus 11 for all rewired inspections. Complete drawing on reverse side. Signed X Title: Date:---6---I&-- FOR DEPARTMENT USE ONLY lI� Date � � .�� _Area �® Application Accepted by Pit or Grout Inspection by �i Date Final Inspection by 1 Date w a i! Additional Comments: ❑ Stk 466-6781 0 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 95201 I� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO7 J CASH J I +.EH 13-24 MEV.1/B 51 7� G T ! r� 4Q~ '3 . i EH 14-28 k ��