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F� 1 � A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 `;-��-- —� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :1;Z7 " "' ,{Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District foi'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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. s nU.;. � l x City /• ^ Lot Size_ �� PM Job Address /. xs Owner's Name 12,400g7 / Address Phone Contractor's Name License No. �' 2 Phone TYPE OF WELLIPUMP:1' NEW WELL ❑ ° WELL REPLACEMENT ❑ DESTRUCTION ❑ I -PUMP INSTALLATION 11K SYSTEM REPAIR 1.3 OTHER ❑ M DISTANCE TO NEAREST: SEPTIC TANK ' I "SEWER LINES r DISPOSAL FLD. PROP. LINE : TI - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 11 Industrial ❑ Open,Bottom ;' 1:1Manteca., Dia. of Well Excavation Dia.'of WellCasing El Domestic/Private ElGravel Pack 07racy Type of Casing— Specifications.. ❑ Public ❑ Other ❑ Delta Depth of Grout Seal %Type of Grout ❑ Irrigation pprox,,Depth ❑,Eastern. Surface Seal Installed by -` Repair Work Done ❑ Type of Pump '"4� + IH.P. I State Work D ne``"' �1 (J) Well Destruction ❑ Well Diameter !Sealing Material stop 501; Depth ! ' Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION -._REPAIR/ADDITION ❑ DESTRUCTION 1-1Moseptic system permitted if public sewer is ✓ n t available within 200 feet.) !! Installation will serve: Residence Commercial— Other �i Number of living units: Number of bed ams 017` 4 �* Character of soil to a depth of 3 feet: r. ter table depth Capaci•i Compartments SEPTIC TANK Type/Mfg �._P TREATMENT PLT rT Method i a r of Disposal , I Distance to nearest:iWell Foundation Property Line #46 107g i o ` _F/ e I r LEACHING LINE "� No. & Length of lines �_�� r --- ---Total•Iength/size— — _ � FILTER BED Distance to nearest: well Foundation Property Line ? SEEPAGE PITS ❑ Depth Size Number 9 SUMPS b Distance to nearest:'�-.y Well Foundation Property Line k DISPOSAL PONDS ❑ hereby certify that I have prepared this,application.and that the wor0will be done in accordance with Sap Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 F 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." Contractors hiring or sub-contracting)signature certifies the following: '9 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's c 6mpensa- tion laws of California." t i The applicant must call for I req 'red inspections. Complete drawing on reverse side. r ' Signed Title: ^•—-`- = Date: 5 l FOR DEPARTMENT USE ONLY / l Application Accepted by! F Date 3`! Area ; r Pit or Grout Inspection by -Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 4 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box,2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED w GASB' R.EC VED BY, "DATE PERMIT'NO. i INFO -ry r F + EH 13-24IREV.101831 1S` dam _J F'S -S`1-W4� tiff EH 1428 -