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APPLICATION FOR PERMIT l 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781: PERMIT EXPIRES TYEAR 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. Job Address f Y �44_ City Lot Size PM Owner's Name04Address Phone `�� Contractor Address License No. � Phone TYP.E.OF WELL/-PIJMP:--- - ❑ NEW WEC1 — '__ WELL REPLACEMENT 71 DESTRUCTION 1-1 a -TYPE PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS r INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial W 0 m Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing � 9 i 7 Domestic/Private C1 Gravel Pack I ❑ Tracy Type of Casing Specifications r k) •n .1 I l Public # iI Other •� F1 Delta Depth of Grout Seal Type of Grout lN1 I l Irrigation —_Approx.'Depth {{ l I Eastern Surface Seal Installed by [err>Repair Work Done ❑ Type of Pump t H.P. State Work Done r i Well Destri,ctian ❑ Well Diameter: t--z-� f Seating Material (top 50'1 - r " yf Depth f 4 � tl filler Material (Below 50'i a TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR,/-ADDITION-•h}---DESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.) Installat of n will serve: =Residence Commercial= Other } Number of living units: Nutmber of bedrooms - s I Character of soil to a'cl p h of 3-feet: Water table depth 3 }F SEPTIC TANK ""❑ T Fe.Mlf # ! -f � �� _p 1 # YP 9 �" '"' cap�cify t No. Compartments ti"! PKG. TREATMENT PLT. ❑I F /.? Metnoa of Dispas�i r Distance to nearest:T: Well FOL;ndat"ion Property Line 1 LEACHING LINE ❑ .^No. & Length oflinesi�- `�-� C Tcjtal length/size I # j FILTER BED) ❑,iDistanbe to nearest:} Well.../- Foundation_,!�X k Property Line SEEPAGE PITS 11' Depth Size Number f E SUMPS ❑ Distance tozriearest: Well 'Fo ndation Property Line f DISPOSAL PONDS ❑ 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 i rules and regulations of the San,Joaquin Local Health,District. Home owner;or licensed agent'iV§ionature certifies thelfollowing."I certify that in the perfbrmance of the work for which this per Tit is issued, I shall not employ an ` - p y y person in,such manneras td'6ecame subject to wort an s compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that i7.the,perforWa-nc of the*+vim for which this permit iS,issued-1.4 hall ernploy,personr:subject to,workman's compensa- tion laws of California." 1-:, - I- I l r." ^ r The applicant must call for all required inspections Complete draw injg on reverse side. f Signed X _ r Title 1 s ,,. Date i ——/X�LFO EPARTMENT-USE ONLY I AP lication Accepted by Date Area P..it oriGrout inspection by to Final Insp ction by Date f " `A ditional Comments: ,. 1DlStk 466-6781,E ❑ Lodi 369-3621 ❑ Manteca 104 ❑ Tracy Z836-6385Vt "* `. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O' Box 2009, Stk., CA 95201 i4 } FEE AMOUNT DUE AMOUNT REMITTED CK i E �j INFO �y CASH RECEIIV/ED BY GATE PERMITNO. * EH13-21fREV."/x51 /f /w� �/� EH 11-28 _ /�/ A