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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �,,. ~, 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San J urn Local Health District. Job Address �� I. m PA n{1� y4��- t� V _- City + Lot Size PM (.1a J^ Phone !a 7--'S 7� Owner's Name ddress f Contractor Address License No Phone TYPE OF WELL/PUMP: NEW WELL W, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER t❑ �. El f DISTANCE TO NEAREST: SEPTIC TANK ., �} ! SEWER LINES DISPOSAL FLD. CQ PROP. LINE sS I Dl5 t-�--�--r- _ FOUNDATION _�— AGRICULTURE WELL OTHER WELL— Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i j r ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -Domestic/Private El Gravel Pack ❑ Tray Type of Casing `� Specifications_. ( t , 1l Deltas Depth of Gro ut'Sea[ TypeJ-Po. out ��tf� �1-1 Public �� ❑ Other_,,,., .I I Irrigation �ptJ Apprax. Depth . I I Eastern 5ur(ace Seal Installed by - Repair Work Done ❑ Type of-Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 �� r Depth s' Filler Material (Below,50'1 TYPE= OF SEPTIC WORK: 'NEW INSTALiATION I ] REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) r3 In ation will serve: Residence_ Commercial— Other , t: iKw J Number a units: Number of bedrooms } Character`oY soil to a dept Water table depth SEPTIC TANK ❑ -Type/Mfg Capacity `r No. Compartments PKG.,TREATMENT PLT. ❑ 1 � _,. X, Method of Disposal Distance to nearest: Well Foundation '" Property Line, Total len th/size- f 'E LEACHING LINE ❑ No. &_Length of lines _ g = FILTER BED ❑ Distance to nearest: Well's Foundation Property Line 1. SEEPAGE PITS � /C 1-"Depth Size Number SUMPS L, Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ '�' 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 District. Home owner or licensed agent,'s signature certifies the following:-1 certify that in the perforrtiani a 6f the+nrork for which this permit.is-issued, 1 shall not ' man's compensation laws of-California." Contractors hiring or subcontracting signature employ any person in such manner as to become subject to wo II certifies the following: "i certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- i tion laws of.California." The applicant-m t call for all require inspections. Complete drawing on reverse side. Signed X Lt Q 92c�.— Title: -e -:5 Date: ► FOR DEPARTMENT USE ONLY Application Accepted by Date Area hq t Date �� Final Inspection by Date Pit or Grout Inspection by , • U Additional Comments: - ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104-s, .v ❑ Tracy 835-6385. .� p AppEica!t__-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 PERINIT'NO. INFO �4� - 5--,?air 3 + EM 1324(REV. /n 5) ' EH 11-2d