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I APPLICATION FOR PERMIT SAI'! JOAQUIN LOCAL HEALTH DIST'IRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) Application rs herebN made to the San Joaquin Local Heath mstrct for a permit to construct and/or insta'd the work t•e•:dn described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. '.,;62'Gr welllpump and the Rules end Rngulations of the San Joaquin' Local Health District. P City �._— Lot Size N Job Address � �f�� -- /� Owner's Name Address �T/ .?�N — —' Contractor's Name 1 Li<enseNo. �} -r�'} Phone TYPE OF WELL/PUMP.' NEW WELL WELL REPLACEry EN i,1 DESTRUCTION L7 PUMP INSTALLATION C GYSTEM REFIAM 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _-- DISPOSAL FLDY _ PROP.LINE _ FOUNDATION AGRICULTURE WELL _— OTHER WELL P1TS15UMP5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC-tUN SPECIFICATIONS ❑Industrial ❑ Open Bottom D Manteca Dia.of Well Excavation Dia.of Well Casing 7 at Casio, Spocifcatiors J DornesticlPrvate �7 Gravel Pack ❑Tracy Ys� d Type of Grout ❑Public 0 Other C: Delta Depth of Grout Seal 1 7- 0 Irrigation --APProx- Depth [IEastern Surface S--21 Installed by Repair Work Done 0Type of Pump H.P. _ State Work Dane 1 Well Destruction © Well Diameter Sealing Material 00p!,01 Depth Filler Material (Below P IR1 AODITIQ N iA- GEST'RUCTION : tNo septic system permitted H public sewer is RK: NEW INSTALLATION G_ RCA F SEPTIC WO available wrthir 2fX7 feet.) TYPE O 5 avers . Installation will serve: Residence t�Commercal.^ Other Number of living units: Number of lxdrogmr. Water table depth 41 , Character of soil to a depth of 3 fee::_ �T !Mi s 2- capacity No. Compartments 2- SEPTIC TANK t. Type/Mfg „ E: x Method of Disposal PKG.TREATMENT PLT. 111 Distance to nearest: Well Foundation Property Line LEACHING L[IJE No. Length of lines Total length/size Ne, -- !F Well FILTER BED t❑ Dstan.e to nearest: �L l Foundation 41 Property Line�Z. J✓/ — iF�Oepth _ _ Size Number r SEEPAGE PITS + SUMPS C Distance to nearest: Well�� Foundailcn �_C> Property Line DISPOSAL PONDS r I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,stale laws,and rules and regulstnxus 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 in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or aub-eodtracting signature employ any PerSpr I cerUfles the following:"1 certify that in the performance of the work for which this permit is issued,;shall employ persons subject to workman's eompensa- tion laws of CsWomis." The epplic8 us t call for all required ins c Sons.Complete drawing on reverse side. Date Signed •__ Title: r I FOR DEPARTMENT USE ONLY I Date Date inal Area Application Accepted by SF _ Data Pit or Grout Inspection by InspeCtign by - - �� l,:9g X71,I��lt' LI tLTIL Additional Comments: Lodi - - ❑Syt 4g5 W1 CI Lodi 3fv 3621 O Manteca 8V-7104 C,Tracy 6�5 I Applicant-Return all Wpies to: Environmental Health PermWServices 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED GAS4 RECEIVED BY GATE PERMIT N0. INFO ] + .E413-2A(RFV.10/611 " i EH iL2b i � 4 1 i r