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APPLICATION FOR PERMIT ov-,N JOAQUIN LL 'AL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PE4MIT 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 irtstam the work herein Or This appicstion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 fo well/pump and the Rules and Repulstions of the San Jospuin L xal Health District. Job Ad&P; 1_/� [�4' / C Lot Size PM 0 per's Name6 [��vAddress _._ ty y� /Addres� E�_ � � Phone �� TYPE OF WELL-PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION &i-- SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � Industrial C Open Bottom F1 Manteca Dia. of Well Excavation Dia. of Well Casirq /-DomesticiPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Spoeftatior» Public C Other ❑ Delta Depth of Grout Seal Type of Grout A-leg-wion ---Approx. DIMf Eastern Lurface Seal Installed by Q _ Repair Work Done Type of PumQ H.P. 5 _ State Work Done �J Well Destruction Well Diameter Sealing Material(top 50'1 __- Depth_ Filler Material(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION L' REPAIR/ADDITION Ll DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial ___ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ ---_ __— ---------Water table depth_ SEPTIC TANK Type/Mfg _________—_—__— Capacity--- No. Compartments PKG. TREATMENT PLT. Method of Disposal _ Distance to nearest: Well Foundation._ Property Line__- 1 _ LEACHING LINE :; No. & Length of lines _ Total length/size `n1� FILTER BED Distarce to nearest: Well _ Foundation_ — Property Line L , SEEPAGE PITS Depth Size _ Number SUMPS Distance to nearest: Wnll —_ __ Foundation __—___ Property Line----- DISPOSAL PONDS C i I hereby certify that I have prepared 1.'s application and that the work will be done in accordance with Sen Joaquin county ordinances, state laws,and rules and regulations of the San Joaqum 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 sham not employ any person in such manner as to become subject to workmsn's compensation laws of California."Contractors hiring or sub-contracting signature Corti, 's the following: "I certify that in th peliormance of the work for which this permit is issued,I shall imploy,persons subject to workman's compense- tion laws of/California." The applica�t must call for all uinfd I ions.6o-rnplete drawing on rse side. z+ / I {/ �iL' Date:1, l Title: Signed X FO EPARTMENT USE ONLY h vsa uvhC•K�� _ Date E 1 Area Application Accepted byC-`'�'� / Final Inspection by J Date Pit or Grout Inspection f�y to ^ ` h ' \` w Additional Comments: Ii ~ Stk 4666781 ❑ L 38q-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT RE.'ITTEDTK RECEIVED BY DATE PERMIINJ. C` ) l LL' r I k-7EN 1121 IREv i . EN 14418 9