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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,;STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , (Complete in Triplicate) 1 Application is hereby made to the San Joaquin aquin 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 sewage or No. 1862 for well/pump and the Rules and R Local Health District. egulations of the San Joaquin i i Job Address/7.�7 3__/C1.�`�o"i..�.t-d-.e�t `�; _"." � � n CiLa. hK2� t" ot Six '',. - PM �- Owner's Name ` Address 1 'Uhone "y Contract l� _ _, 1 AddressPo' tP7_ �r License No. 2 Phone 'TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1 DESTRUCTION .7 i PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ 'f (DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE rM I I I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E -1 Industrial ❑ Open Bottom U Manteca Dia. of Well Excavation Dia. of Well Casing 1❑ Domestic/Private CI Gravel Pack U Tracy C Type of Casing Specifications I �G Public r F, Other C Delta Depth of Grout Seal 1 ! .� ,h p -- Type of Grout { C Irrigation _--Approx. Depth C Eastern �� Surface Seal Installed by I Repair Work Done C' Type of Pump H.P. ''J State Work Done 4 :Well Destruction U Well Diameter Sealing Material (top 501 _ p f 1 1 Depth Filler.Material (Below 501 (TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION C (No septic system permitted if public sewer is available within 200 feet.) Installation-will-serve:—R nce• —Commercial' err Nu`mb'er of living units: Number of b r I Citaracterof-soil to-a-depth-of 3-feet: - ---- - - �. � Water table depth Ll 0 V 4— ,SEPTIC TANK /��Type/Mf ,9C r C_apaa / No. Compartments ,.{ IPKG3 REATMENT PLT. 17r +�"tY jt�� r 1 4r `M—ethod of Disppsal 1 Distance to nearest: Well Foundation'. _�O Property Line _S f 17i r LEACHING LINE No. & Length of lines f t � O ;Tota! length/size- FILTER BED C Distance to nearest: Well FoundationJ r Property Line . SE PAGE.PITS R--Depth _ S A Tom"' 3f Size= r�—` 1 �— SUMPS U: Distance to nearest: Well r �, ,z Foundation 1 { •• _�3��- ,�_��'u � gr Line r DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquincounty oriinances, state laws, and rules and regulations of the San Joaquin Local Health District. - r t=.. E \ r Home owner or licensed agent's signature certifies the.following: "I certify that in the performance of the work.for which this permit isissued"I shall not employ any person in such manner as to become subject to workman's compensation laws of CalifoTiiia."-Cdntractdr's-hiring or subcontracting signature i certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall e a • I pe employ persons subject to workrnans cbinpensa- ' tion laws of California." The applicant call for all roquired inspections. Complete drawing on reverse sid Signed X t Title: V '�' _ Date: FOR DEPARTMENT USE ONLY J i Application Accepted by _ Date r Area a Pit or Grout Inspection by /\IA— Date Final Inspection by J Date i Additional-Comments: �J 'C1 Stk 466-6781 U 23 Lodi 369-3621 U Manteca 6 -7104 U Tracy 8356385 IApplicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2008, Stk., CA 95201 ) r - FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +EH 13-24MEV.;is5) rEH 14-28