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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT e 1601 E. HAZE,T:b 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 ' made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well and the Rules and Regulations of the permit to construct and/or install the work herein described. This application is Local Health District. { r,zr' San Joaquin ;L4 T V?c- 2ECp.�� Job Address Q airyL� Lot Size A Owner's Name E D Address # — Phone Contractor's NameY —� License No. TYPE OF WELL/PUMP; NEW WELL ❑ Phone PUMP INSTALLATION ❑� WELL REPLACEMENT ❑ DESTRUCTION Li i SYSTEM REPAIR E21 K OTHER ElDISTANCE TO NEAREST: SEPTIC TANK a r �SEWER LINES 1 FOUNDATION s: 4 �— DISPOSAL FLD. PROP: INE AGRICULTURE WELL OTHER WELL �4 INTENDED USE TYPE OF WELL PROBLEMCONSTRUCTION SPEGFICATiONS PITS/SUMPS I ❑Industrial LJ Open Bottom d ❑ Domestic/ Private ❑ Manteca Dia, of Well Excavation ❑ Gravel Pack ❑ Tracy ❑ Public v Type of Casing ❑ Other E1 Delta Depth of'Grout Seal O Irrigation --Approx. Depth ❑ Eastern Repair Work Done Q Surface Seal installed by TYpe of .Pump —�` H.P. Well Destruction ❑ Well Diameter State Work Done _ Sealing Material (top 5o') Depth i Filler M Dia, of Well Casing Specifications Type of Grout eternal ;Below 50'I } TYPE OF SEP TlC WORK,: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ ;No septic system permitted if f:. Inst will serve: Residence available within 200 feet.l Comrnefcial Other Number of living units: "-- Number of, bedroorris Character of soil to a depthf 3 feet: SEPTIC TANK E' Type/Mfg -; . Water table depth PKG. TREATMENT PLT.'[2 Capacity_J(a9212— No. Cornpartliients 7 / Method of Disposal Distance to nearest: ` Well ©O Foundation . Property Line LEACHING LINE FILTER BED ; No. & Length of lines Z Q Distance to nearest: a Well pp Total length/size � i --�— Foundation E � Property Line�O W sewer is SEEPAGE PiTS (rept' ^/-, rs # Sizes _ Number SUMPS s p Distance to nearest: j. Weil J £ L�.0 �_ Foundation _YdIJ' _ Property Line ^ZAML ' DISPOSAL PONDS ❑ k.� I hereby certify that !have. prepared•thls 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' Heaith District. Home owner or licensed agent's signature certifies subject to ' certify that in the performance of the work for which this,permit is issued, I shall not employ any person g such manner as to become subject io workman's in 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:"y � r The applicant must call for allr qulred.insjiections. 'Complete drawing on reverse side. Signed Xy- ; } Application Accepted by fPif or Grout lnspection by Additional Comments: ❑ Stk 466-6781 Applicant -Return all ni FEE INFO Title:. 1 Date:--� ✓� � r FOR -DEPARTMENT 11SE,ONLY s Date Area ate mal Inspection by I� to Date xfi 369-3621 } ❑ ' Manteca 823-7104 ❑ Tracy 635-6385" I to: Environmental Health•Permit/Services 1601 E. Hazelton Ave., P.O; Box 2009, Stk., CA 95201 i{ , AMOUNT DUE AMOUNT REMITTED CASH RECEIVED'8Y1. DATE EH 1324 (REV. 10193) EH 1425 PERMIT" No. M, 11 0 1 5-13 640