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APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT-- t 1601 E. HAZELTON AVE.;�S'TOCKTON, CA + Telephone (209) 466-6781 3 PERMIT EXPIRES T 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 a made H 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 in co District: pplication is Job Addressi:tj:.° , e ~1;1 ' f Nil rx.. ,., X...- City .11640-L Lot Size r "Owner's PM Name zeOR( - �U Address J1 Q r� J1 Phone J 3 t Contractor ti I51). SOrS ddress TYPE OF WELL/PUMP: r L�1��6J � icense No. o S/ f/ NEW.WELL ❑ Phone Y WELL REPLACEMENT ❑ DESTRUCTION ❑ t ` PUMP INSTALLATION ❑ �. C DISTANCE TO NEA'RESfi SEPTIC TANK-`--, SYSTEM REPAIR ❑ OTHER ❑ # SEWER LINES NF UNDATION .T DISPOSAL FLD. PROP.-CINE AGRICULTURE WELL OTHER WELL C rlNTENDED USE.x4�4 �� PITS/SUMPS TYPE OF WELL PFOOBL� EM-AREA CONSTRUCTION SPECIFICATIONS T �`:❑$industrial ❑ Open �OnOm •❑.Manteca ' ❑ Domestic/Private �. . „t ' Dia.of Well Excavation ❑ Gravel Pack`,, ❑ Tracy "Type of CasingRia. of Well Casing ❑ Public ❑ Other--- +-- -- -- Specifications ❑ Delta ❑ irrigation i Depth of Grout Seal —'�Approx._Depth r.,.❑.Eastern---__sType of Grout Repair Work Done ❑ T 'I'' urface Seal installed..by P YPa of Pump �� Well Destruction O Wi4 Diameter H P State Work Done De th # Sealing Material (top 500) 1 P Filler Material (Below 50') } TYPE OF SEPTIC WORK:i NE INSTArz,LLATION ❑ REPAiRJgp 1Ti0 �+/ 4 DESTRUCTipN O fN° septic system permitted if public sewer is installation will serve: Residence L7C L~ ' F available within 200 feet.) r Number of living units: u - r`T Commercial Other I �+ „ g ( Number of bedrooms Character of soil to a depth of,3 feel: t SEPTIC TANK T pe/4fg2rzd nj u i Water table depth j PKG. TREATMENT PLT. EJ ` °""" "'"�`- -_ _CaPayrty ` _ —F GNo: Compartments Distance to nearest: ' "Walk_ I Method of Disposal ih r _ Foundation�f Property P rty Line LEACHING LiNE - 1 X'Nol. & Lengtf�,of,lines "°r C) FILTER BED' e '•Total length/size C� ❑ Distance to nearest: _'Well Foundation Property Line I ! Y SEEPAGE PiTS w Depth r Size SUMPS "❑ istance to nearest: Well ( f.. Number ( v ` DISPOSAL PONDS,`w Foundation ❑ � _ .. _P Property Line hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws a rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies thefollowing- and employ any person g such manner as to become subject to workman's compensation laws of California."Contractor's hiring_or.sub contracting signature g: "I certify that in the performance of the work for which this permit is issued, 1 shall not Y certifies the following:"I certify-th6t'in the'perform'ance of the'work for which this permit is iss Calif shall C to tion laws of Calif P P Y persons subject to workman's comperl The applicant ust ca for all re w _ j nspell Co ete drawing reverse ide Signed X 1 ' II:. Title: _ s Date: i FOR DEPARTMENT USE N Application Accepted by c Q Date Area Pit or Grout Inspection by Date Final Inspection by 5 Additional Comments: ��' r 4, � Date ❑ Sik 466-6781 of 369-3621 ❑ Man eca 823-7104 't Applicant Return all oPies to: En!`vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo 200g Stk.yCA 95201 I! s FEE AMOUNT DUE _ - 4T INFO AMOUNT REMITTED CK RECEIVED BY i CASH DATE PERMI7'NO. �'EH14-24fRkV.iif35i ��, �0 r-..n