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-f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I—ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 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 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. Job Address �� __Y/� _. �r City Lot Size e PM Owner's Name t9l/tl0Tl � ddress Phone Contractor J�� '"' /t's, _ 3 ..Address_"RIg License No. b Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION "1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER D / DISTANCE TO NEAREST: SEPTIC TANK /��ljJ tSEWER LINES -�~ DISPOSAL FLD.� PROP. LINE L FOUNDATION _��AGRICULTURE WELL OTHER WELL PITS/SUMPS /� t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ � T� :DIndustrial J Open Bottom E] Manteca Dia. of Well Excavation r— _ 1 pia. of Well Casing N omestic!Private 'ravel Pack Ll Tracy Type of Casing Specifications F"1 Public ❑ Other n Delta Depth of Grout Seal _ y T_� `e of Grout i I Irrigation p��Approx. Depth I I Eastern Surf a Seal Installed by !� Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter _ Scaling Material Depth Filler Material 1Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION 1'1 t REPAIR/ADDITION I I DESTRUCTION I ! tNo septic system permitted if public sewer is ~ ( available within 200 feet.f _ Installation will serve: Residence f Commercial , Other Number of living units: Number of bedrooms ry Character of soil to a depth of 3 feet: —Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity ('-,No- Compartments PKG. TREATMENT PLT. ❑ "r f Method of Disposal ` Distance to nearest: Well _ Foundation Property Line J LEACHING LINE fl No- & Length of lines ; Total length/size_ I _ FILTER BED ❑ Distance to nearest: Well Foundation — r Property Line ' I � i I SEEPAGE PITS 1 1 Depth Size Number I SUMPS Ll Distance to nearest: Well Foundation Property Line ' I DISPOSAL PONDS ❑ i t-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 03trict. ✓ J d i 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 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." i The applican u r quir s. Complete drawing on rev si §ide. —y� Q I Si Title:13 x_ =ned -7� -- Date: �7q r . FOR DEPARTMENT USE LY ` 1 Application Accepted by f�- �•' A ••�-Datrs Area Pit or Grout Inspection by ^� `` Date rz d Final Inspection by Additional Comments; / /� �( ❑ Stk 466-6781 ❑ Lodi 369.3621 C Manteca 82.3-7104 Tracy f635-&385 ` 9e AAV ^1" ; BN Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, t5 k.; CA 95201 FEE INFO AMOUNT DUE.�� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24IREV.I/h5) G7� EH 14-2E /+DS ��o d I �L� .