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._: APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDr. L (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. - ,` d °�= rCrt 'T6d.C'�D City �� 'rot Size� PM Job Address t, Owner's Name 01971"' /G0/2 w!/'^ Address W ` r e Phone y Contractor Address "License 'hone TYPE OF WELL/PUMP: *� `-NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F1SYSTEM REPAIR❑ OTHER ❑ 6E,_!-,5-`N _ PROP. LINE !i DI STAN CE�TO NEAREST: SEPTIC�TANK SEWER LINES DISPOSAL FLO. AGRICULTURE WELL FOUNDATION OTHER WELL PITS/SUMPS INTENDED USE 4'.TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ED Industrial -Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private « © Gravel Pack is �❑ Tracy `• Type of Casing Specifications f ❑ Public Lil Oihe�sr� ©,Delta *`. �. Depth of Grout Seal Type of Grout k ❑ irrigation ► al's pprox. Depth `D Eastern' . .Surface Seal Installed by Repair Work Done ElType of`Pump ..H.P: State Work Done— Well Destruction Q Well Diameter .d- 'SeNing_Material Atop 50'1 r' j Depth ''" -✓x Filler`Material (Below 50') 1 i TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION ID DESTRUCTION ❑ INo septic system permitted if public sewer is i! available within 200 feet.) it y Installation wiH serve:-.,Resideri`ce_ Commercial Other Number of-living units: Number of bedroomsA '- # ` Character of soil toa;depth of 3 feet: r,rgG` Water table depth f SEPTIC TANK t,Ij ❑ Type/Mfg Capacity�1- r"dLYNo. Compartments PKG. TREATMENT PLT. ❑ ;, ty r '' Method of Disposal r Distance to nearest: WellFoundation �di'. PropeLine AI' i LEACHING LINE ❑ No. & Length of lines- r " ' J. T<otaal length/size- �r Y ;'`'FILTER BED ❑ '...Distance-to nearest: Wellocv Foundation _ :--�P.Tperty Line\__451__r SEEPAGE PITS ❑ Depth 1 Size :SUMPS L] Distance to nearest: Well Foundation Property L1rie k `DISPOSAL PONDS j ❑ I , lcatibn•and that,the work will be done in accordance with San Joaquin county ordinance4, state laws, and I hereby certify that I have prepared thisappi , . 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 theworkfor which this permit is issued,_(shall-not t employ any person in such manner as to become subject to workmah 's compensation laws of California."Contractor's hiring or sub-contracting signature r 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 must call•for all re "ed ins ctions. mplete drawing on reverse side. 4 t w 41 } Title�,t-�... i Date: T A Signed X i FOR DEPARTMENT USE OTILY , Application Accepted by c T Date Area { Date ),-FiflaI�Qpegtion by f C5Date s Pit or Grout inspection by Additional Comments: i ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ! FEE ....AMOUNT DUE T- --AMOUNT REMITTED- _CK' `""" EF,1EIVEYDATE PERMIT No. o -- 'INFO CASH% -_ - + � EH 13-24.5REv.. /8.51 l ..r. EH 14-28 .� ��