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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT fav , ( V SSI# 1601 E.- IiAZE"LTON A1`/E., STOCKTON, CA 1� Telephone (209)'466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . iComplete.in Triplicate/ SAN JOA ` QU1N ` '.l"Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the viro� tion is made in compliance with San"Joaquin County Ordinance-No.549 for sewage or No. 1862 for well/pump and the Rules and RegulafioTl§' an;Joaquin Local Health District. . �a �.; = d Job Address __ __ .__ � City a Lot Sizes PM SWOwner's Name,, '�I/�aCLY1.i dty(ess S P Phone �� ,g 4 Contractor's Name " « se Nc. �� 16 Z 3 7— Phone jdi I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'PUMP;INSTALLATION D SYSTEM REPAIR &0 OTHER ❑ DISTANCE TO,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL T+ OTHER WELL" PITS/SUMPS TENDED USE TYPE OF WELL PROBLEM AREA- @QItlSTR17CTI0N SPECIFICATIONS Industrial D Open Bottom —a-Manteca- .Dia "of-Well Excavation- -Dia. of Well Casing I ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications 0 Public ❑-Other ❑ Delta Depth of Grout Sea! Type of Grout ❑ Irrigation i1 _-4pprox. D pth ❑ Eastern Surface Seal Installed by ti Repair Work Done ❑ Typelof Pump t-JH P. S State Work Done Well Destruction ❑ WelllDiameter Sealing Material (top RY) i Depth > . Filler Material (Below 501 t1 TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ll� F4 available within 200 feet.) „Installation will serve: Residence Commercial_ Other a Number of living units $ Number of bedrooms Character of soil to a deptha 3 feel:° }. Water table depth T a � . SEPTIC TANK ❑, Type/Mfg Capacity" '' f No. Compartments PKG. TREATMENT PLT. ❑ '' ` t F �.� � i 1 &� Method of Disposal DistarV to nearest: Well --Foundation Property'Line i LEACHING LINE ❑ No..& Length of.lines r Total length%size f �.r.... FILTER BED , ❑ ,Distance to nearest: Well Foundation Property Line" SEEPAGE PITS ❑ "Depth Size Number SUMPS , ❑ 'Distance to nearest Well Foundation Property Line DISPOSAL 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 Saih Joaquin Local Health District. Home owner or licensed ageett's!'Signature certifies the following: '�,I_certify that in the performance of the work for which this permit is issued !shall not employ any person in such manner as to became subject to workman's:compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: hat in t rformance of the work for "Wf i ,which thispermit is issued,l shall employ persons subject to workman'scompensa- tion laws of CaiiforThe applicant m 'inspecti omplete drawing on rever rHe, � J / I Signed Title. FOR DEPARTMENT USE ONLY Application Accepted b 1 Date AJr rea ' Pit or Grout Inspection by N w Dae Final Inspection by Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621AAanteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental 4 Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 i I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY _ DATE PERM- W146. I i:+ EH 13241REV.10/83) o EH 14-28 S