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`r APPLICATION FOR-PERMIT SAN JOAQUIN 'L•OCAL4HEALTH DISTRICT °I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES"! YEAR AFROM DATE ISSUED n� (Complete tri Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described,TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ um a Local Health'District. - pump and the Rules and Regulations of the San Joaquin Job Address ' r ' s { f 3 t. City Lot Size X ! �o Owner's Name PM s Address' - Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ ~-- License No. WELL REPLACEMENT ❑ R�Phone r� - PUMP INSTALLATION ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR [I OTHER C) �- SEWER LINES DISPOSAL FLD. � FOUNDATION AGRICULTURE WELL PROP. LINE Q1� INTENDED USE OTHER WELL�� TYPE OF PITS/SUMPS ❑ Industrial WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [Toper) Bohm ❑ Domestic/Private ❑ Manteca' Dia. of Well Excavation. ❑ Grave! Pack L7 Tracy 1 T Dia. of Well Casing Q Public ❑ Other i Ty of:Casing ❑ Delta . Depth of Grout Seal Specifications ❑ Irrigation ---Approx. Depth LJ Eastern Type of Grout Repair Work Done ❑ T Surface Seal Installed by Type of Pump —� H.P. Well Destruction ❑ Well Diameter `'" Wo`rk�Don f Sealing Material (top 50') State TYPE OF Depth Filler Material (Below 50') v SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence Commercial, vailable within 200 feet.) Number of living units: Other;�� Number,of bedrooms > Character Of soil to a depth of 3 feet: SEPTIC TANK ( i Type/Mfg _ Water table depth PK G. TREATMENT PLT. ❑ + Capacity No. Compartments a Distance to crest: We11 Method of Disposal Foundation Property Line LEACHING LINE ❑F NO. & Lengthof lines"--' r FILTER BED LJrest: . Distance to neaTotal length/size Well Foundation f Property Line k SEEPAGE PITS El Depth - 1 SUMPS Size Number t Q., Distance to 6earest: Well / r3'` DISPOSAL PONDS ❑ I'i Foundation PropertyYL`irie -' I hereby.certify that I have prepared this application and that the-work will be done in accordance_with_San.Joaquin-coup - rules and regulations of the San Joaquin Local Health District. " _ Home owner or licensed agent's signature certifies the following: T ty ordinances state laws,—and .; the employ any person in such manner as to become subject to workman's rc compensation lawsormance of.California."Contractor's work for which or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall em to permit is issued, I shall not tion laws of California." 4 p y persons subject to workman's compensa- The applicant must call for all required ins r pections. Complete drawing on reverse side. i Signed Title: I Date: 14 4 FOR DEPARTMENT USE ONLY Application Accepted by ,� Date Area U Pit or Grout Inspection j Date Final Inspection by Additional Comments: i Date - ❑ Stk 466-6781 ❑ Lodi 369-3621 _❑ Manteca 623-7104 5-6385 Applicant- Return all copies to: Environmentall Health Permit/Services 1601 E.❑Hazel on Tracy Af e P.O. Box 2009, Stk., CA 95201 p I i T DUE r' . 'AMOUNT AMOUNT REMITTEb RECEIVED BY CASH DATE PERMIT'No. + EH 13-24 IREV,i i y 517 EH 7428 - f