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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PEA 411 1601 E. HAZELTON ON AVE., STOCKTON, CA G Irv, f Telephone (209) 466-6781 RpN 19,92 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED it j; (Complete in Triplicate) SRV/� STH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This a ation 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. q a�37 r 1►'� a&�L�/� City Z" "" t/ Lot Size PM Job Address 1 �R _ Owner's Name / Address q mo Phone eer f {'�_, d�0 Phonet � Contractor- r d`f..]C.I'v Address A License N TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' 'PUMP INSTALLATION g SYSTEM REPAIR ❑ OTHER ❑ . . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION -AGRICULTURE WELL OTHER.WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS; Ll Industrial ❑ Open Bottom -E] Manteca t1Dia. of Well Excavation Dia. of Well Casing 9 Domestic/Private EJ Gravel Pack � ❑ Tracy ` � � `Type of Casing Specifications ❑ Public [I Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation -Approx. Depth !1 1 Eastern surface Seal Installed by � s Repair Work Done M Type of Pump /� — H P State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 50'1 ` 'TYPE OF SEPTIC WORK: -NEW INSTALLATION 11 'REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is c _ S available within 200 feet.) lnstalfation will serve: Residence_ Commercial kOther Number of,living.units,,' "< k `• Number of..bedraoms ! F Character of soil to a depth of 3 feet: Water table depth I. SEPTIC TANK 0 Type/Mfg ' Capacity No, Compartments PKG. TREATMENT PET. ❑ -`1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 .Depth Size Number SUMPS C1 'Distance to nearest: Well Foundation�� Property Line T� { DISPOSAL PONDS ' �r ...I hereby certify that'I have,prepared this application and that the work will be done in accordance witti San Joaquin county ordinances;state'laws�nd -� rules and regulations of the San Joaquin Local Health District. a 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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 applicant m all for all require spe ns. Complete drawing on reverse side. f +�� i Signed X Title: Date: // FOR D RTMEN SE ONLY ; _ i Application Accepted by Date Area k Pit or Grout Inspection by Date Final Inspection by Dat I Additional Comments: 1 F1Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 C' FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT NO. INFO F'j/�J Q +,EH 13-24(REV.V K 5) i/_ (/ V EH 14-26