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,l APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA ;! Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,. (Complete in Triplicate) I 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 "k made in compliance with San Joaquin County Ordinance No.549 for sewage of No. 1862 for well/pump and the Rules and Regulations of the Sari Joaquin r Local Health District. A 1 •' ' ' . o �. .. t /I Job Address 4: City -Lot Size PM Owner's Name ' Address Phone Contractor r ,�Y ` Address` x Gt S ! _ LiLc�ense No. Phone_ � TYPE OF'WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE�WELL OTHER WELL PITS/SUMPS j INTENDEI?t SE TYPE OF WELL PROBLEM AREA!(CONSTRUCTION SPECIFICATIONS ❑ Industrial ED',Open Bottom ,,�D.-Manteca, Dia-of Well Excava-tion Dia. of Well Casing Domestic/Private ❑'Gravel Pack ❑ Tr y z 13rt`�-�"Type of Casing y �- -� Specifications ❑ Public' ❑:]Other C7'Dekta Depth ofGrou; Seal Type of Grout 1 ^❑ Irrigation . _app o.x. Depth' ❑ Eastern ;y Surface Seal''Installed-/by Repair Work Done ❑ Type of Pump H.P. f State Work Done_ 1 i Well Destruction ❑ Well Diameter - ^;"'�a`Sealing Material',Itap 50'!f Depth" Filler Material ( el w 50',) n I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑' (No septic system"permitted if public sewer is evailable within 2W feet.] Installatrdn will serve: Residence 'Commercial * Other ' J Numbe:iif.living units: 1" Number of be ms £, i i _ Character of soil to a deptco h of 3 feet: Water table depth SEPTIC,TANK ❑ , Type/MfgTt� Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ j. et o o isposal' Distance to nearest: Well Fo ndation Property Line r' LEACHING LINE : No. & Length of lines ',Total leng h/size ' �`` - o-Q ' FILTER IBED ❑EE` siar}ce to nearest:...,,,,,;;y-Well. O "�IFoundation ' Property Line I SEEPAGE PITS O-�LDepth Size t" /J/{�NNn,_...e,_/_A9_ f�5om j SUMPS; --f'4 t .o Distanceto nearest 'Well ' Foundaiibn. 2011 Proparty�Li DISPOSAL PONDS ❑ Il s I herebyicertify that I have prepared this application and that the work will be done in accordance wit Sari 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- 1 ce l y that in n th 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."Conteactorts hiring or sub-contracting signature certifieslkhe followi : "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 IaW6 of Califo ia." r I` The applicant mu II far all req a nspections. Complstedrawing on reverse side. 4 i Signed X > Title Of +�� — Date: FOR DEPARTMENT USE ONLY Application Accepted by ' Date Area / 0 Pit or Grout Inspection by �- Date ',nal I Cion by Date s t Additional Comments: ❑ 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 95201 017 z. IFEENFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVEIJDATE PERMIT N/O. - +-EH 13-241REv:-1/951 7" `l 1/ � •- ,...e.<'`EF 1428'- _