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J v APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ;1 . 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 Cityt Size aFd _- n rs made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and a Rules and Regulations of theoaquin Local Health District. ('� am ,Job Address _ L Owner's Name Address Phone I Cont is Name Lrcen o. 31 Phone TYPE OF WELL/PUMP: NEW WELL,Q WELL REPLACEMENT ❑ DESTRUCTION C}.•. PUMP-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑:. DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP:LINE:< FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA i�CONSTRUCTION SPECIFICATIONS = ❑ Industrial ❑ Open Bottom ❑ Manteca t.Dia..of Well Excavation Dia. o{Well Casing ❑ DomestWPrivate ❑ Gravel-Pack ❑Tracy 'Type of Casing Specifications ❑ Public Cl Other ❑ Qelta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by z Repair Work Done ❑ Type of Pump H.P. I State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Materi4al (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION7-11 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �9 r ! , t available within 200 feet.) Installation wi01 serve: Residence�`Commercial_ Other Number of living units: Number of bedrooms Character of soil to ah of 3 feet: Ater table depth SEPTIC TANK V Type/Mfg C pacify o. Compartments r PKG.TREATMENT PLT.0VMethod of Disposal / ("11 . Distance to nearest: Well Foundation 14! Property Line 15A- -r �q LEACHING LINE No. &Length of lines W Total length/size FILTER BED 13 Distance Distance to nearest: Well ` Foundation_ ' Property SEEPAGE PITS ) Depth 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 San Joaquin Local Health District. Home owner or licenead agent's signature certifies the fogowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any percon 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,1 shall employ persons subject to workman's compensa- tion laws of Criifomia." Th cantm call for 11 requI7 'nn ons.Cor�Qte d rse side. Sign X� �� T� C`c rL v Date: �FORDEPAR Ef,1T USE ONLY Application Accepted by Data 7'�/`�r�u Area f/ PI r Grout Inspection by a e 9-,214' Final Inspection by ate A '. nal Comments: Stk 468.6781 ❑ Lodi 389-3821 ❑ Manteca 823-7104 ❑ Tracy '835-6385 ,cant- Return all copies to: Environmental Health Permit/Serv,ces 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INNFFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMrr•No. .EH, tAev.,pita, #C:!:� —�� #e,,'41-23