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y� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (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 Joaquin Local Health District. I _ Job Address � ��/ - "'' City IMleal Lot Size��O`� PM Owner's Name Day � �5 Address ► ��.5��7 N:f/%a�Q Phone 423 Contractor �� t iy/Jf�7 �e4 Address f©1 SO �� 7�93e�23 �323 Y el License No. Phone �. - ��- -r - -.... _ TYPE OF WELL/PUMP: NEW WELL '4 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'X " '""'"'^"-SYSTEM REPAIR-C} 4 �. �; O`HER'❑ / DISTANCE TO NEAREST: SEPTIC TANK /00r+ SEWER LINES � DISPOSAL FLO.J1V - PROP. LINE ' t FOUNDATION '�� AGRICULTURE WELL OTHER WELLJ_W`I PITS/SUMPS INTENDED_ USE TYPE OF-WELL,- - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑„Open Bottom Manteca Dia. of Well Excavation /1 Dia. of Well Casing j Domestic/Private Gravel Pack ❑Tracy Type of Casing,f�� /"^ D SpecificationsC�c�.r �� 71 Public fth//er !!oo j F] Delta Depth of Grout Seal 163 /yl. Type of Grout _ g_ i I Irrigation .Ap�bx.'Depth I ] Eastern- .......Surface-Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter. bSealing Material (top 501) Depth y Filler Material (Below 50'1 ` TYPE OF SEPTIC WORK: NEW INSTALLATION I,1` REPAIR/ADDITION.I i -.DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet► Installation will-serve:—Residence�`�� Commercial ” Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg+1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ z Method of Disposal Distance to nearest: Well 3 Foundation PropertyLinei LEACHING UNE ❑ No..A Length of lines Total length/size O FILTER BED E) Distance to 'nearest: Well F Foundation 'Property Line I - '(SEEPAGE PITS 11 Depth I Size _ Number e Y SUMPS a ❑ Distance.to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I r 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 Di"strict. 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 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 t call for all g:dZ' Z:ns. Complete drawing on reverse side. Signed X F Cl✓L _ Title: Date: i FOR DEPARTMENT USE ONLY ! y Application Accepted by Date 1 ' Area 1 -' Pit I�Grou�Inspection by ` � � � Date J l / °� Final Inspection by Date>�� _ .«._. Additional Comments: Iti a ❑ Stk 466-67$1 — ❑ Lodi"30-3821 ❑ Manteca, 8'23-7104 ❑ Tracy 835=6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEEO AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. +.EH 13-24(REV.I H6) 165, C70 r�_f y y _30► EH t4-28