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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 application is made in compliance with Sari 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. / .S O �. Q 1r fid'. - !/S/a,&L Job Address Cit Lot Size PM Owners Name Mato __.-___.— Address &!S5;)g Phone 722--3-60 a Contrac� Y Address 80-o�•r License No3 �ZG Phon � 2L TYPE OF WEI l PUMP: i NEW WELL J WELL REPLACFMFNT 1 DESTRUCTION ❑ PUMP INSTALLATION L) SYSTEM REPAIR ( OTHER I] DISTANCEe_ TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.______ P_ROP,TLINE FOUNDATION .- AGRICULTURE WELL — OTHER WELL. _ _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U Industrial - U Open Bottom n Manteca Dia. of Well Excavation f Dia. of Well Casing U Domestic/Private `-I Gravel Pack ❑ Tracy Type of Casing_ Specifications ('1 Public ;=1 Other L Delta Depth of Grout Seal �`. —'Type of Grout I I Irrigation Approx. Depth I Eastern Surfaco Sudl Installed by Repair Work Done U Type of Pump H.P_ State Work Done Well Destruction ❑ Well Diameter ►-•/ Sealing Material (top 501 Depth 'Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION RL'PAIR/ADDITION I : DESTRUCTION I I INn septic system permitted if piihlic sewer is available within 200 feet.) Installation will serve: Resid nceCommercial e, Other f Number of living units: Number ovileoroolrils, 9 Character of soil to a depth of 3 feet: `�r Water table depth L SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. LJ r rr,._ - —Method-of Di sal --- --- Distance to nearest: Well D.. —Foundation _1Q- ._._.. Progeny line LEACHING LINE + Ll No. & Length o1 lines' r— Total length/size FILTER BED V.U�',Distance to nearest: �yWall�' Foundation Proporty_Line SEEPAGE PITSDepit, Size .__ Number ie SUMPS L: Distance to-nearest: —Well Foundation. ,Jz�.._ _ .... Property yLit DISPOSAL PONDS C I hereby certity that I have prepared this application and that Ute-work will be done in accordance with San!Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D3trict.j_ y Homo ownor or licensed agent's signature certifies the,following:-1 certify that in the performance of the wank for which this permt is issued, I shall not employ any person in such manner as to become-subject to workman's compensation laws of California." Contractors hiring or sub contracting signatur certifies the following: "I certify that in the perforriiance'of the.work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mustt;; l uiro 'nspeetions.tComplate drawing on reverse i Signed X � Title: ��•��` Date;,�5�,�-1—��"�",�` FOR DEPARTMENT USE ONLY Application Accepted by Date- w Area .__. j( ' i itit/�r Grout Inspection by Dater �Ffnal Inspection by � � f Date V �� Additional Comments: D Stk 466-6781 L Lodi- 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FE E INFO AMOUNT CUE AMOUNT REMITTED CK 8 CASH RECEIVED 8Y DATE PERMIT NO. 9�.EH 13-24 IREV,t n 5 i EH U-28