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!'"• �� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED ! (Complete in Triplicate) 111 ter; 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. and the Rulestand Reguulations oft San Joaquin Local Health District. 1862 for well/pump Job Address 9f C Subdivision Name 5" Owner's Name Address � 'f-j�a Phone ' Contractor's Name .r � �- License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 3'jam (�� 'L C4 PUMP INSTALLATION [J SYSTEM REPAIR ❑, OTHER i 1` DISTANCE TO NEAREST: SEPTIC TANK - [G SEWER LINES DISPOSAL FLD, PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ar Industrial � Open Bottom E] Manteca Dia, of Well Excavation ❑ Domestic/Private Gravel Pack Trac /// ❑ y Dia. of Well Casing Public ❑j Other ❑ Delta L Irrigation � Type of Casing f! Approx, � Eastern F_fCathodic Protection, Depth Specifications ❑Geophysical Depth of Grout Seal ❑Other Type of Grout ^. Surface Seal Installed by 42 4A 21- Repair Work Done ❑J Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units:. Number of bedrooms Lot size {' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments. # PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINElines of Length No. &— �I 9 � Total length/size -- "' "'� r. -��'�� -•---- .x FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONOS I 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. i 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 workmar� 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 compensation laws of California." The applican est cal for ll required inspections, Complete draw'ng on reverse side. j Signed / Title: Date: �( MOENT SE ONLY Application Accepted 7by Area V/ ❑ Stk Additional Comments: ❑ Lodi 369-3621 ✓ � r ; Pit or Grout Inspection by Date i? Manteca 823-7104 �� Final Inspection by -_ Date 6 [j Tracy 835-6385 1-1-frkeij Applicant - Return all copie Environmental Health Permit/Services 1601 E. Hazel on Ave., P.O. Box 2009, Stk., CA L951201 4-e)4-4, FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. �} n'r7GJ��" =INFO - EH 13-24 RENT/�..14 �(f �Y�i- c:.cl[�r c� �- r3 4 - ��rs* c.�.rr�Gr}c�•- 1�'/sz 500 14.14-2 "� lYJ,.irli �� wLICU) b [�"c4C-r.d-C*A' � ��- S�►'�I3 �I� Gw�4.c�4y. SJ-�•.f- - hu i7'1�ld�t� Gaf�h 5 1— nearL�1}hy Cir J I cr,n��,is G4F1: k -r- 4+24, �$4 �