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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON,' CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) _ r ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in , r made H compliance with San Joaquin County Ordinance No. stall the work herein described. This application is Local Health District. "`- 549 for sewage or No. 1862 for well/ um r: .7is P p.and the Rules and Regulations of the San Joaquin Job Address �� n i .. .. t•• tEi iIr -'-�� City � d Lot Size Owner's Name iQ =S „n "_` PM Address ��Jl _ Phone Contractor/ q�p/�� ".^. -___�- J v'! :s -C Address v "!']J�; TYPE OF WELL/PUMP: License No' / - i NEW WELL ❑ WELL REPLACEMENT Phone b PUMP INSTALLATION ❑ DESTRUCTION ❑- ` DISTANCE TO NEAREST: ,SEPTIC TANK SYSTEM REPAIR:❑ 1' , 'i- SEWER LINESi..� THE� ��'+� FOUNDATION ---I' DISP\OSA FLD. PROR. LINE AGRICULTURE WELL + I OTHEd WELL K.I INTENDED USE TYPE OF WELL J PITS/SUMPS ' ❑ Industrial PRO E CONSTRUCTfON SPECIFICATIONS ❑.Open Bottom ' ❑ Domestic/Private ' ❑ Manteca +� f / Dia. of Well Excavation I ID'Gravel Pack y T i Dia, of,Wel! Casin ❑ Public ❑ Trac C ype of Casing r �'� 4 , g . i t C7'(5ther Specifications ' �d ❑ Irrigation i tf ❑ Delta v Depth of Grout Seal _Approx. Depth ❑ Eastern �� Surface Seal Installed by / TYPe.of Grout Repair Work Done ❑ Type of Pump Well Destruction H.P. 1 ❑ Well Diameter State'Work Done '^ Sealing Material (top 50') w y +� k Depth TYPE OfiLSEPTIC,WORK: Filler Material (Below 50'► ? qty ANEW INSTALLATION ❑. (Below r ) 4 DESTRUCTION ❑ (No septic system permitted if Installation:will se e:y Residence I ; available within 200 feet.) Public sewer'is 1 i V 1Commercial, -_ r.OthFr. '�„� -- �' ( Number of living units: -Aum reb ofjbedrooms r! IIJ Character of soil fo a dep 3 feet:' ih of N - SEPTIC TANK J� � -- E Type/Mfg i 'W ate,tabp hPKG. TREATMENT PLT'L --5--.- /-•-• IC,,Capcy o. U Compartments ff 1 Distance to near6st:3 Well Method of Disposal Foundation � Property Line LEACHING LINE No. & Length of lines __p(—($��' �L� �Y FILTER BED Distance-to-nearest: -Well , Total length/size Foundation j ,t _.QL Property Line SEEPAGE PITS 4d' Uepth ✓ I Siz R l SUMPS istance to nearest: We�I - Number DISPOSAL PONDS ❑ 'L�°undation /�---Property----line I hereby certify that I have prepared this application and that the work will-be.done inlaccordance with San Joaquin cou�nryLo-rd�ina e ` rules and regulations of t e,San Joaquin.Locav Health-District. Home owner or licensed agent's signature certifies the following: I # ordinances, state laws, and f employ an L.1_ P Y e Person in such manner as to become subject to workman's compensation laws of California.`"Con_k",for 5-'h hiring or subcontracting signature td= certify that in the performance of the,work for which this parmit is issued, i shall not certifies theCalifornia."I certify that in the performance of the work for which this permit is issued, I shall em to following: ., i tion laws Of Califo _ p persons subject to workman's compensa- rr The appfican st call for all requir ins t- t pections. Complete drawing on a rse side. 1 Signed Title: j Date: FOR DEPARTMENT USE ONLY Application Accepted Date f�/ - 6 —'^Ptt or rout Inspection by ` � . _ Area I Date Final Inspection by j Additional Comments: r �h Dare j ❑'Stk 466-6781 ❑ Lodi 369-3621 ❑Manteca 823x7104 '� 1 r''\ ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 ,'St9 CA 95201 a I ? 'r .' FEE_ INFOAMOUNTDUE --AMOUNT - .=-gECE1VEb 8Y-^" ��- CASH LATE EH 1a-z+iaty.,�n sr PERMIT NO. EH 1420 �Q' , i , �• �� r