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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 . , t, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED br I (Complete in Triplicate). Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herelri 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 ciN^1A/C6•f• Lot Size -l'•� PM a 1 _ Address- �9-2--__ � Owners-Name - ► `S l�z Phone •? i Contractors Nam e License No. TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ) IDISTANCE TO NEAREST:!SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f 1 INTENDED USE %TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E] i Industrial ❑ Open Bottom ❑ Manteca t Diaiof Well Excavation Dia-of Well Casing !❑ Domestic/Private LJ Gravel Pack l C3Tracy Type of,Casing Specifications EI Public ❑ Other :I 11Delta r" .� Depth of Grout Seal - Type of Grout ❑ Irrigation --Approx. Depth 11,Eastern Surface Seal Installed by Work Done ❑ Type of Pump I H.P. State Work Done _ » F Well Destruction ❑ Well Diameter� Sealing Material Itop 60'1 t ,r Depth Filler Material (Below 51y) s TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0» DESTRUCTION ❑ (No septic system permitted if public sewer is .� k _-available within 200 feet.!jr— k� Installation will serve: Residence�� Commercial Y- Othi:r r t l Number of living units:— Number of bedrooms kCharacter of soil to a depth of 3 feet:'I # r ' ' - Wetter table depth ❑ Type/Mfg Capacity . L No.Compartments PKG. TREATMENT PLT.❑ 4 i. % ` l �„{ Method of 0 Istate MAO Distance to nearest: Wall" Foundation //�' Property'Lrne LEACHING LINE ❑ No. & Length of lines Total len gth/FILTER BED ❑ Distance tc nearest: Well Foun ' n Property LinaSEEPAGE PITS ❑ Depth. - Size Number SUMPS ❑ Distance to nearest: Well 1 ndation Property LineDISPOSAL PONDS ❑I hereby certify that I have prepared this application anti that the work will be done in accordance with San Joaquin countrules and regulations of the San Joaquin Local Health District: k 1 tt Home owner or licensed agem's signature certifies the following: "I certify that in the performance ofthe work for which this permit is issue , satro employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or suarxmtracting signature tcertifiss me following;"I certify that In the performance of the work for which this permit is issued,I shell employ persons subject to workman's compensai tion laws of California." The applicant must call tgrol required Inspections. Cgimplate drawing on revs a•eider- .�• -— 6=1 }Signed X Title: Date: I � {��F\)OR DEPARTMENT USE ONLY [ r `! t Application Accepted by "�`^ `"" � - Date `g Arta 1� Pit or Grout Inspection by t Date Final Inspection by Date 4- s t Additional Comments: ❑ Stk 4866781 ❑ Lodi 369-3621 fl Manteca 823-7104 ❑ Tracy 835-8386 Applicant- Return all copies to: Environmental Health Permit/Services 1001 E. Hazelton Ave.,P.O. Box 2009,.M., CA 95201 r C FEE gMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMn`NO. setaxa laev•truss! O , 0 0 ✓ 0 1e $b Z Ex taxa _ i