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. 4 5 k.APPLICATION F611 PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j Application is heaeby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is I 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. ob Address �/ `?f � City / Lot Size C1 PM .,,'I �l/�vfff/f!� Address Phone Owner's Name Q� Contractor 00T£/'�- ��Address � [" lO '�, License No. J4OST Phone"7�6 TYPE OF WELL/PUMP:.,,,,,,.,..„.__NEW,WELL ❑_._ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ Vv SYSTEM REPAIR ❑' OTHER ❑ D! TO NEAREST: SEPTIC TANK SEWER LINES a DISPOSAL FLO. PROP. LINE FOUNDATION ICULTURE WELL -OTHER WELL" ' s PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS SPECIFICATIONS ❑ industrial I] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel PackY 'EI Tracy Type of Casing Specifications M Public t Ll Other ❑ Delta Depth of Grout Seal M Type out �. ' I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by f - . Repair Work Done ❑ Type-of-Pumpw - --H:P: -----•-- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 {� f Depth Filler Material (Below 501 - s TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIOfy DESTRUCTION l I (No septic system permitted if public sewer is 4 _ available within 200 feet.) r �T'F L f Installation will serve: Residence_ Commercial Other Number of,living units: Number of bedrooms J i Character of soil to a depth of 3 feet: } Water table depth j ! SEPTIC TANK ❑e Type/Mfg Capacity ? ---ho. Compartments ~ PKG. TREATMENT PLT. ❑ rST`�ie��' Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED a ❑ Distance to nearest: Well Foundations Property Line SEEPAGE PITS Depth T,_`_ _Size 90<a �� '- — Number 7- SUMPS SUMPS ❑I Distance to nearest: Well Foundation l?-2- Property Line lT` 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 rules and regulations of the San Joaquin Local Health.District. �� Y 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 c rtify 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." a The applicant must r all requ' ins ns. plate drawing on reverse side. r, Signed X Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date��~ j Area , } t Pit or Grout Inspection b Date Final Inspection by �a G Date - -ti Additional Comments: ❑ Stk 1466-6781 ❑ Lodi 369-3621 11 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 ..AMOUNT REMITTED CASH s RECEIVED BY DATE PERMIT NO. INFO + EH 13-24 IREV.I. i H 51 U EH 14-26