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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 4 YEAR FROM DATE ISSUED f (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 1 made in compliance with San 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. Job Address 18665 S Jackt ri City Manteca _ Lot Size PM Rmd Phone Owner's Name&&per & Address 59�- r Contractor. Martin & S 1 Address 5 Reed Road License No.360-852 Phone 84790394 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 19 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 00 r SEWER LINES 100'+ DISPOSAL FLD.�QQ�_ PROP. LINE 600 t l FOUNDATION 20' AGRICULTURE WELLNO e OTHER WELL 60' PITS/SUMPS None INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of W-11 Casing _ ® Steel pomestic/Private � Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1-1 Other n Delta Depth of Grout Seal 50 Type of Grout � tQ�te -- I I Irrigation Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump RlIbm H.P. w State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 k Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence — Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth + SEPTIC TANK ❑ Type/Mfg Capacity- 11 No:-Compartments PKG. TREATMENT PLT. 0 r Method of Disposal ( Distance to nearest: .'Well' Foundation FProperty Line LEACHING LINE ❑ No. & Length of lines Total length/size 'FILTER BED ❑ Distance to nearest: Well .4* Foundation °Property Line I i t kI SEEPAGE PITS I I. Depth�� size umber �—_ Nt t 'Pro a Line SUMPS L1 Distance to nearest: WeIE Foundation—'Property DISPOSAL PONDS ❑ - I hereby certify that I have prepared this application and Ghat the work-will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local H alth.Di§trict. # Home owner or licensed agent's signature certifies the f611owing_=.;A,certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to wdrkman'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." +. # F{ ' � f 4 The applicanj st call for all requi ms ti ns. Complete awing on verse side. i _ Title: Signed X Date: i t FO PAR E USE ONLY # Application Accepted by Date rea Pit or Grout Inspection byDate Final I spection byDate /� Additional Comments: ';/ A �� ' �� t• f�f �f//�'="ti ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑.Tracy 835-6385 '' p Jt °f�rfd✓l Nom, -�r-;j k Applicant- Return all copies to: Environmental Health Pefmif/Services 1601 E. Hazelton Ave., P.O.4cix 2009, Stk., CA 95201 t MOUNT DUE AMOUNT REMITTEDFASH T�RE{EIVEQ�BY q DATE PERMIT'NO. j INFO 4 td / 9+.Eli 13-24IgEV.1in5Y � 'k i s� �� R EH 14-26