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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE1:TON 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 2} 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 �Q� � City Lot Size PM ' L Address - Phone C L Owner's Name + �� V is V� ' Address �~ F License No. O Phone sjd� ( Contractor ' TYPE OF WELL/PUMP: ' NEW WELL ❑ WELL REPLACEMENT❑ j DESTRUCTION ❑ `.f, PUMP INSTALLATION E) SYSTEM REPAIR ❑ , OTHER ❑ ff DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' ,DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTiiER;WELLk PITS/SUMPS INTENDED USE I TWE F WELL PROBLEM AREA CONST.RUCT10N.-SPECIFICATIONS p Industrial G ❑lOpen Bottom,--•❑-Manteca-..., ---t Dia. of Weil-Excavation -- -- Dia of-Weld Casing ' 1 I i / Specifications ❑ Domestic/Private 1 '❑'Gravel Pack i ❑ Tracy i Type of Casing — 0 T of Grout ❑ Public # ` ❑ Other ❑ Delta ° ;Depth of Grout Seal Type 1 i ElIrrigation 11 pprox-Depth ❑Eastern Surface Seal Installed by _ Repair Work Done 01 Type a of Piump ' H.P. State Work Done lr , 1 Well Destructio O Well Diameter j Sealing Material (top 5011' ' Depth _ Filler I (Below 56'1 I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAI ❑ DESTRUCTION ❑ (No septic system permitted'rf public sewer is L available within 200 feet.} Instalkation will serve: Residence Commercial_ her ' J Number droo s ! Number of living units: j '4, r Water table depth Character of soil to a depth 61,3 feet: SEPTIC TANK L� T pe/Mfg .dt Capacity/?00— No. Compartments Method of Disposal,^-., t r''A - PKG. TREATMENT PLT. ❑ "} Distance to nearest: i Well 100'+ undation—�o Property Line r I Total length/size pQ x ' k LEACHING LINE I �No. & Length of lines , FILTER BED l ❑ Distance to nearest: Well 1001 Foundation oZ0 Property Line Z SEEPAGE PITS LDepth �S Size 3 Number SUMPS ❑' Distance to nearest: WeilO�i= Foundation Property Line DISPOSAL PONDS ❑, 3 I hereby certify that I have prepared this applicatiofii and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin LocallHealth 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 shall not I employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature certifies the following:111 certify that in the pe`rformar ce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ji The applicant m t all for all re l uired inspetions.•Complete drawing on reverse side. r j Title: V.P Date: ir,- Signed i p I FOR-DE ARTMENT•USE-ONL-Y—"""""""'�- } l�Area Application Accepted by Date- r1�f �—- i or-Grout-Inspection D to- _ nal-Inspection bye -� Additional Comments: ; ElStk 466-6781 ElLodi 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 FEE AMOUNT DUE AMOUNT REMITTED' CASH RECEIVED BY DATE EPEIRIMIT'NO. INFO r .+ EH 13-241REV.I/85] ? -.. k EH 1426 ^ a 1