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r F - r APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 r PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED w ,.(Complete in Triplicate) r 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. t5-: Job Address t City Lot Size 1 PM e.- Owner's N mem f Address — Phone M A ,ddres � License No. Z Z _ Ph— one ContractorF r s _ — TYPE OF WELL/PUMP_" ' __])NEW W€Ll 0_ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION SY E] STEM REPAIR ❑ OTHER ❑ r , DISTANCE TO NEAREST_ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \ FDUNDAploN.. AGRICULTUREyWELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom W R_Manteca,__._Dia. of Well Excavation Dia. of Well Casing \`W t \�tt;111111 El Domestic/Private 171 Gravel Pack ❑ Tracy Type of Casing Specifications , ❑ Public ❑ Other ❑ DefS Depth of Grout Seal Type of Grout El Irrigation — Apprax. Depth ❑eastern Surface Seal Installed by " Repair Work Done LJ Type of Pump H.P, State Work Done \ ) Well Destruction 0 Well Diameter `Sealing Material 46p-50') Fl.Depth I 4 Filler Material IBelow 50') t TYiP-E`OF SEPTIC WORK': NEW INSTALLATION LJ REPAIR-1ADDITION 0' DESTRUCTION ❑ (No septic system permitted if public sewer is t.. ; available within 200 feet.) ' Installation will serve: tResidence— Commercial-- ther Kumtier of living units:!_. Number of bedrooms � a � Character of soil to a depth of 3 feet: � - ; —Water table depth SEPTIC TANK r❑ Type/Mfg :Capacity No. Compartments $ ` Method of Disposal 'PKG. TREATMENT PLT. ❑ } 0 a y Distance to nearest:- Well Foundation_&) Property Line i� LEACHING;LINE JIB No. & Length of lines 2 _ Total length/size �r,, F1L'TER--BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depthlt ✓� Size Number -a--SU PS El Distance to nearest: Well f Foundation r Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and 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. 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, l 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 ceriifies the following: "I certify that in the performanceoif the work for which this permit,is issued, I shall employ persons subject to workman's compensa- tion'laws ofICalifornia. " The applicat must/11 II for all required ins actions. Complete drawing on reverse side. ,- Signed X Title:' Date: �•� �� - EE .� FOR DEPAR ENT USE ONLY Application Accepted by i or Grourlrlspection by �J Date L�___gFinal Inspection by Date Additional Comments: ❑ Stk 466:6781 ❑ Lodi 369 3621 El Manteca 823-7104 O Tracy 8355-6385 - 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 PERMIT NO. INFO i �+ EH 13-24[REV,tin51 EH 1428 / ♦ Q