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'X APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ME4CN i�� 4? ! r�f,+'F Job Address /Na4 — CityLot Size PM iOwners Name ddress Q ` �� Phone 'tet+ �� Y7 Contractor Mix Address ? d License No.4& Phone! TYPE OF WELL/PUMP: NM WELL ❑ WELL REPLACEN461T ❑ DESTRUCTION ❑ PUMP INSTAL TION❑ '�"'�"' -SYSTENf-REPAIR OTHfR ❑- I DISTANCE TO NEAREST: SEIPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL n OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --"'❑`Industrial"'-"'"""'�'"`" f" -Open-Bottom--- �1-Manteca—rt.Dia-of-Well-Excavation) _Dia.,.of-Well,-Casin9 omestic/Private ❑ Gravel Pack ❑ Tracy f. Type of Casing Specifications - 4 i { if € Type of Grout I'] Public ❑ O``ther ❑ Delta f Depth of Grout Seal I I I Irrigation _ih_A�prox. Depth ( I Eastern R,Pdrface Seal Installed by - Repair Work Done.. L] of of Pump H.P. !" State Work Dane Well Destruction LJ Well D ameter r-- Sealing_Material (top 50') _ i Depth t Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION [ I�REPAIR/ADDITION l 1 DESTRUCTION l 1 INo septic system permitted if public sewer is II Jr ; available within 200 feet.) Installation will serve: Residence Commercial Other i !� Number of living units: I� Number of bedrooms 'rtl Character of soil to a depth lof 3 feet: '- Water table depth ( SEPTIC TANK ❑ (Type/Mfg Capacity k No. Compartments PKG. TREATMENT PLT. El Method of Disposal C ti Distance torn arest:- � Well Foundation Property Line LEACHING LINE ❑ !No. & Length of linesb� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I I Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r t 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 i Home owner or licensed agent's signature ltifie's 4 following: "I certify that in the performance of the work for which this permit is issued, f 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 certifies the following: "I carti y 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." 11I I The applica req s. Complete drawing on revers ' e. I Signed X Title: Date: it FOR DEPARTMENT USE LY , Application Accepted by Date ~ Area /gypq I Pit or Grout Inspection by I� Date Final Inspection by Date < / Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies:to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i I FEE AMCK OUNT DUE AMOUNT REMITTED T CASH RECEIVED 8Y DATE PERMINO. ' + EH 13-24(REV,1 95) 3/ EH 14-2e