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- APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON 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 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. 1 _ Job Address Q � l Ven u City W1 Lot Size PM Owner's Name _ ��] �. Df 1 Address �C rnQh l�lX, Phone {� UZa CBD (� r Contractor Address License No. p Phone 2w- TYPE OF:WELL/PUMP: w NEW WELL ,Nj WELL REPLACE-MENTr❑ DESTRUCTION Q ° TPUMP INSTALLATION 11 SYSTEM REPAIR•❑ OTHER DISTANCE.TO NEAREST• SEPTIC-TANK� '� A .SEWER LINES • z �� a DISPOSAL•fLD.N PROP i LINE FOUNDATION AGRICULTURE WELL OTHER.WELL PITS%SUMPS I INTENDED USE TYPE OF WELL v PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind u trial ❑ Open Bottom 0 Manteca Dia. of Well Excavation 'S ` Y Dia. of Well Casing d �rfiD ; El Gravel Pack- .. ❑ Tracy/ "" Type of Casing � �- t/�- Specifications.. ❑ Public �r ❑ Other ElDelta-j Depth of Grout Seal v Type of Grout a4^90- 4 ❑ Irrigation --Appr8x. Depth O Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump " ' H.P. F State Work Done Well Destruction ❑ Well Diameter V,F Sealing Material {top 50'} } 1 k • Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK:,FNEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTION ❑`(No septic systern permitted if public sewer-k; I �— r, i -_— available within 200 feet.) , Installation will serve: Residence_. Commercial a_� Other t Number of living units:.{ Number of bedrooms - r � • ,_ 4 � Character of soil to a depth of 3 feet: Water table depth e i SEPTIC TANK {pti. Type/Mfg Capacity No. Compartments i• PKG. TREATMENT PLT. ❑ it Method of Disposal Distance to nearest: Well Foundation PropLeiiy Line F LEACHING LINE Q. _No. & Len th of lines �' '_. ~Total length/size_ �:�'a FILTER BED ❑�D.istance i�nearest: Well � F �rq J y Foundation Property (rine SEEPAGE PITS ❑ Depth _ _ Size f Number SUMPS Q Distance to nearest: Well — Fo ndation Property Liner ' DISPOSAL PONDS ❑ Cs { � --)!71 I hereby certify that I have prepared this application and that the work will be done in accordance with San coup Joaquin I rules and regulations of the San Joaquin Local Health District. q ty`yordinances, state laws, en� 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 hot 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,I shall employ persons subject to workman's compensa- tion laws of California." " The applican si call for qu'! i c 'o S. Complete drawing on re } side. ` yf Signed Title: `�/yL�l-- g : ...-.,.�,,. ,� j�G.��LGG.L Date: ; r �P T USE ONLY Application Accepted b y Date JR�Aree Pit or Grout Inspe n by Date Final Inspection by Date c Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 C1 Manteca 823-71 Q Tracy 835- ; 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 CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REY.t/E57 �K3 � ` �® EH 14-28