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APPLICATION FOR PERMIT ^ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6791 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 sawage or No. 1062 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District. �O Cit Lot Size PM Job Address 4,0 ^ /!t �P ,1 J�![l Phone (//!/ Owoei s Name ddress Contractor 00001 001 se No hone TYPE OF WEL !PUMP: ' NEW L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER 11 •.E– - DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SPTIC TANK _ SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom C3Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1, VI Public _ __❑ Other �—r0 Delta Depth of Grout Seal _ Type of Grout I I Imitation v^ —Apf)rox. Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump _— H.P. a State Work Done_ Well Destruction"' ❑—Well Diameter Sealing Material !toss 50'1 Depth Filleroatefial(Below 50') TYPE OF SEPTIC WORK. NEW INSTALLATION I REPAIR!`DDITION I I D ST DICTION I I INo septic system permitted if public se4sN available within 200 lest.! 1 Installation will serve: Res dente_ Commercial_gOtfier. Number o1 riving units: Number of bedrooms_12 Character of snit to a depth of 3 feet: Water tape depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments)PKG. TREATMENT PLT. ❑ _� t Method of Disposal,Distance to nearest: Well J`:1 itFoundation L1 Property Line 00 LEACHING LINE ❑ No. & Length of lines r�11 Total length/size 70 �cFILTER BED ❑ Distance to neeresC WeIV. L Foundetion� Property LinaQfLSE II Dep i Number �SUMPS ❑ istante to nearest: Well oundation Property Line L PONDS �P 1 hereby certify that I have pared this application and that the work 1 be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of th 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. 1 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." The applican most call Ecy all r� ffla4 pl drawing m raver Signed X ��/'`l//� T— Title: / fJ— Date: FOR DEPARTMENT USE ONLY Application Accepted by Ff no Area ❑' r Grout Inspectipn bye I�,�L� Defe Final Inspection by Date Additbnal Comments: ❑ Stk 4668781 ❑ Lodi 3833621 ❑ Mantes 823-7104 ❑Tracy 835-6185 ^ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stir, CA 95201 FEE INFO DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. NFO r EH " IREV. EH;4 L