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:E APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 *r �, "....`. PERMIT EXPIRES 1:YEAR FROM DATE ISSUED ' (Complete in.Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to corisfruct and/or install the work herein described. This application is made in compliance with San Joaquin County Ord-mance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ity Lot Size � �c--.� PM Owner's Name ' dress ''_ Phone 1 Contractor. Address S71d � �!��License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E3DISTANCE TO NEAREST: SEPTIC TANK " , -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION "s. _AGRICULTURLN E ELL, OTHER WELL, PITS/SUMPS 111 } INTENDED USE F TYPE OF WELL.;.L PROBLEM AREA CONSTRUCTION SPECIFICATIONS F ❑ Industrial : ❑ Open Bottom 10 Manteca Dia. of Well Excavation ` Dia. of Well Casing, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracylyl Type-of„Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal € Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by ! ' Repair Work Done`# ❑ Type of Pump `H.P. _ $tate Werk Done Well Destruct of n ❑ Well Diamet'er . a Sealing Material (top 501 k Depth` '" Filler Material (Below 50'), TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDIT40N- -*.DESTRUCTION,,❑ (No septic system permitted if public sewer is F_ , — a ailable within 200 feet.) Installation will serve: Residence!Gommrc eiel-• Other rIi 4 . F - f 'E Number of living units: _' xNumber of bedrooms Character of soil to'a depth of;3'feet: Water table depth SEPTIC TANK Q fT.ype/Mfg —Capacity No. Compartments PKG. TREATMENT PLT. L1J r.s Method of Disposal Distance to nearest: Well Foundation Property LineV. LEACHING LINE �a CI No. & Length of lines I ` Total length/size ' FILTER BED ❑' Distance to nearest: Well .Foundation Property Line x f ,r I L . SEEPAGE PITS ,G_I�Depth Size * Number i SUMPS ❑ Distance to nearest: Well��L Foundation f Property Line ' t .�-01_SPOSAL 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. Homeowner 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 riot employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 applicant ust call for all k 'rad inspections. Complete drawing on reverse side. Signed ��"�"t® , Title: Date: �� Z' # FOR DEPARTMENT USE ONLY I `{ �1Q.t O Application Accepted by I- - //;7 Date- rea Pit or Grout Inspection by Date Final In 'ction by Date i/`�!/Y Additional Comments: r ❑ Stk 466-6781 kkodi ;369-3621 ❑ Manteca 823 04 f' Cl Tracy 835-.6385 t, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, .� -. FEE - -- ----C INFO AMOUNT DUE 1r,' - AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. + EH 1324(REV. /a 5) '� + ,. T� ^� EH 1428 .........T.—..-,...� �..,,��.C�-. ,,..� .'�7 "'.— r —..•.,.,.o„r � t� R / ,�