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x APPLICATION FOR PERMIT -SAN J,OAQUIN LOCAL HEALTH DISTRICT 1601 EJ 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / Q� Job Addressf-f__._ r City LotSize PM Owner's Name ° 1 ddress 7!7 /I.0 M7TY R= 6��ane �o�� -a Contractorl/d I/So�4 i�lzl Address License Noir TYPE-OF WELL/PUMP: -NEW WELLWELL REPLACEMENT 17 -DESTRUCTION 71i4 PUMP INSTALLATION 1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I�1 D r SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION ______J AGRICULTURE WELL OTHER WELL PITS/SUMPS`"� , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f r t+ c © Industrial � Open Bottom 71 Manteca J Dia- of Well Excavation— J - - - ---Dia. of Well Casing i. `Domestic/Private ❑ Gravel Pack ❑ Tra' Type of Casing e- Specifications n Public CI Other n DeFt�a Depth of Grout Seal Typ6•of rout I I Irrigation �..Approx. Depth Eastern urface Seal Installed by I '� Repair Work Done ❑ Type of Pump ,-, l H.P. State Work Done _ t� Well Destruction ❑ Well Diameter Sealing Material (top 50'I v` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 . DESTRUCTION I I (No septic system permitted if public sewer is , L 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: - - v. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I� . Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length.of lines �M Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS ❑ 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 performance of the work for which this permit is issued, I shall not r employ any person in such manner as to become subject.lto 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." I1 The applicant must call for all required i pec ions. Complete I drawing on reveise side. Signed 4 / lCytiJl/u / 'lam -- Title: �-� �-�� Date: IL FOR DEPARTMENT USE ONLY Applica ' Accepted by Date �� -� Area 2— -Pit o Grou nspection by��f"'� IDate7 ~�60 Final Inspection bySDate J3U Additional Comments: II! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy ,635-6385 _ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton.Ave.; P.O: Boz M,'Sik., CA 95201 FEEA OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH f +.EH 13-24 tREV.r/H 51 G0S.0� [/I :T u" / EH 14-26 E- h