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I Ti APPLICATION FOR PERMIT 9� SAN JOAQUIN LOCAL HEALTH DISTRICT OCT 2 0 li%7 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1ENVIROMF1,1TA& HEALTH PERMIT EXPIRES 1-YEAR FROM DATE ISSUED FFIRMIT/SERVICES !+ " (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 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. r ,� 7 T 4/� - City Lot Size PM r Job Address —�'/ // Owner's Name d Address ,L,�^ Phone I Contractor�� Address_ ��icense No. Phone TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION RE"C81 M REPAIR ❑ OTHER 11 r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES., _DISPOSAL�FLD. PROP. LINE _ �... . -.FOUNDATION: AGRICULTURE WELL., OTHER.WELL j�{T51_SU�1.15� -- =-+ IIINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS EI1] Industrial i; ❑ Open,Bottom 19-Manteca-A Dia, of Well Excavation Dia. of Well Casing �,� l T -pe of Casin Specifications' Domestic/Private 0 Gravel Pack racy YPeI 9 Depth of Grout Seal Type of Grout ("] Public ❑ Other ❑ Delta p I I Irrigation 77..Approx. Depth I 1 Eastern Surface Seel installed by 4�is+ g"If - H pState Work DoneRepair Work,Done Q Type of PumpWell Destruction O Well Diameter — Sealing Material atop 50'1Depth. /s� Filler Material !Below 50'1YPF OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I i DESTRUCTION I I INo septic system permitted i( public si available within 200.feet.) r Installationt will �rve encs_ Commercial— Other Number of.living-units: Num edrooms Character o f soil-to a depth of 3 feet: Wai- table depth L 1. � 1 SEPTIC TANK i I. ❑ Type/Mfg Capacity No.'Compartments -0 1'k Method of Disposal PKG, TREATMENT PLDO ; l \ Distance to nearest: Well Foundation Pro perty.Line -� f _ ❑ No•& Length of lines Totahlength/size` LEACHING GINE ' ta FILTER BEDI El Distance to nearest: Well Foundation Property Line Number SEEPAGE SEEPAGE PITS ,�l I Depth Size a ❑, Distance to nearest ✓'Well Foundation Property Line f DISPOSAL PONDS ��'0 li r I hareby certify that I have prepared this application a4.that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health'District. Horne.owner.-or-Gcansedagent:s signafure certifies the-Glowing: "I 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 workman'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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m r requir tions. Complete drawing on r rs ide. j Date: A Signed X Title: 4%% , FO EPARTMENT USE ONLY , i �UArea 2/� f� k -- Application Accepted by Date 411�- Pit or Grout Inspection by Date Final Inspection by 4601 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant = Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 R I , FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT IVO. INFO ZA +.EH 13-24 IREV.1/H 5) 0 � EH 14-26 u I