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t APPLICATION FOR PERMIT r f O j 3 w"'� �`�� SAN JOAQUIN LOCAL HEALTH DISTRICT `�' t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 12- sS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l v �1 c S . 3S (Complete in Triplicate) WV P?,,. -- Application is heleby 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 welltpump and the Rules and Regulations of the San Joaquin Local Health District. ( l //�� Job Addre + ` City0Lot SizeJ_0 �U W PM Address � Phone � T n.".nnr'c N w rw+ wCLL (J WELL REPLACEMENT ' DESTRUCTION ov PUMP INSTALLATION SYSTEM REPAIR L-J OTHER U DISTANCE TO NEAREST: SEPTIC TANK SFWFR I rNrc � TYPE.OF WELL/PUMP: ..h NEW WELL 0 WELL REPLA'CEMENI L7 -- utS I nut,11vry PUMP INSTALLATION 17 SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELL ""OTHER WELi_�'�'"�"PITS/SUMPS INTENDED USE TYPE OF WELL s PROBLEM AREA CONSTRUCTION SPECIFICATIONS t!J D Industrial } ❑'Open Bottom (5Manteca Dia. of Well Excavation Dia. of Well Casing L/`} ❑ Domestic/Private_e� f _❑ Gravel Pack ❑ Tracy.,- Type of Casing Specifications ti F] Public D Other Cl Delta - Depth of Grout Seal Type of Grout 1,1 Irrigation —:.Approxr Depth 1.1 Eastern Surface Seal installed by Repair Work Done ❑ Type of,Pump H.P. State Work Done Well Destruction 0 Well'Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 — 4 TYPE DF SEPTIC WORK: NEW INSTALLATION REPAIR)ADDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence Commercial ther Number of living units Nftroroo i QCharacter of soil to a depth of 3 f14 T.Water table depth SEPTIC TANK Type/ Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ !�} , Method Property Distance to nearest: Well Foundation CProperty Li � r ,l. X • LEACHING LINE No. & Length of lines wTotal length/size FILTER BED ❑ Distance to nearest: Well_VIOL4-Foundation _.- Property SEEPAGE PITS I I Depth Size Number .SUMPS Ll Distance to nearest:_ Well Foundation, Property Line . <' i DISPOSAL PONDS ❑ I, I hereby certity�that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ander;' 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 I 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 applicant st call fo re ired inspections. Complete drawing on reverse 2-dap Title: Date: Signed X � _ FOR DEPARTMENT USE ONLY Ap lication Accepted by Datt� r Area out Inspection by Data Final Inspection by Date Additional Comments: ,Q ❑ Silk"466-6781 Cod 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 , -o FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVE BY DATE PER NO. INFO +.EH13-241REVA/K5) !/ r'� p` 7 EH 14"211 „TT