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S f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA � i t' Telephone (209) 466-6781 1444 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �98 !j (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workheir/fie oribe"(i:�Tti+s appli 'axidn is n ,9of� � 4 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regrurlationn�« s iltri g�ri Joaquin Local Health District ce 111014'1��/1121 Job Address d#hgoe /)/--,0/) AP,0- Lot Size_e 17//� PM Owner's Naru � �rAddress C71-. d Phone Contractor Address License No: �.ZS� P TYPE OF WELL/PUMP: NEW WELL ❑ WELr REPLACEMENT ❑ DESTRUCTION ❑ 7FJ2 W — 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. E FOUNDATION AGRICULTURE WELL — OTHER WELL 3D0J5r-, PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t 'ffd,Public Cl Other Cl Delta Depth of Grout Seal Type of Grout , I I Irrigation 4rox. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I i DESTRUCTION l I (No septic system permitted if public sewer is ` 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: p Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS � ❑ Distance to nearast:-,"Wel I � r� 'Voundation �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 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 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." The appli us II r all re 'ed inspections. Complete drawing on r rse side Signed X Title: Date: FOR EPARTMENT US LY tt Application Accepted by Date Area ./ J Pit or Grout Inspection by Date Final Inspecti by Date✓' Additional Comments: a- �� ❑ Stk 466-6781 ❑ Lodi 369-3621 IManteca 823-7104 ❑ Trac 835-6385 Applicant- Return all copies to: Environmental HegItFi P m�//Services 1601 E. Hazelto}Ave., P.O. Box 2005, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. 1 +.EH 13-24{AEV.r i H sf —E�� EH 1428