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kk APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED °•r (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 H compliance with San Joaquin CountOrdinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. - yll .Q �j Joh Address / f// J`f. 6 I GtyLot Size PM Owner's Name e o Address Phone 1 Contractor � a• � ; Address F License No._�}7�' Qd_6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ �^ WELL EPLACEMENT [JDESTRUCTIO - PUMP.INSTALLATION ❑— r_ _.__ _ ....- TRU T SYSTEM ,-- REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE,_.,. 4 FOUNDATION P AGRICULTURE WELL OTHER WELL PITS/SUMPS, INTENDED USE- � TYPE OF;WEL-L —PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;� ! ❑'Industrial ❑ Open Bottom L2'Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private © Gravel Pack ❑!racy Type of Casing g j Specifications ❑ Public ID Other ) ❑ Delta Depth of Grout Seal Type of Grout 171 Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Dane LJType of Pump , i H.p I i State Work Done�+ Well Destruction ❑ Weil Diameferl Sealing Material (top 50'I ) I 3 Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION ❑. DESTRUCTION 1 '(No septic system permiLpuwer is € available within 200 feet Installation will serve: Residence! Commercial_ Other t Number of living units: Number.of bedrooms Character of soil to a depth of 3 feetWater table depth SEPTIC TANK 1 ❑ Type/Mfg ? Capacity No. Compartments i PKG. TREATMENT PLT. D 1 'c 1 i Method of Disposal I bistance{to nearest: -: WellFoundation Property Line �--- -- 1 i I LEACH ING`CINET ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: , Well Foundation Property Line 4 SEEPAGE PITS ❑ Depth 1 Size Number I SUMPS ❑ , Distance to nearest: Well T DISPOSAL PONDS F] Foundation 'Property Line hereby certify that I have prepared this application and ihat 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: "I certify that in the performance of the work for which this permit is issued, I shall not GE 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 certify that in the performance of the work for which t is,permit is issued tion laws of California." , I shall employ persons subject to workman's compensa- a A The applican ust call forIr quired inspections. Complete drawing.on reverse side. I e Signed X t e $I ' Title: _a t",e Date: f Y FOR DEP MENT USE ONLY �,Q i� Application Accepted by r pate 1�Z� °J Ar",k '+ Pit or Grout Inspection by Date Final inspection by lyd � I Date r-'. � ..' Ad itioFH omments: � �tk 8781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 /Aplicaeturn all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y FEE ;-�-AMOUNT-DUE^-^� -AMOUNT'REMITTED K- € INFO C SH RICEIVE� 9YY DATE' PERMIT*NO. '+ EH 13-24(REV.1/85) i� ✓ �', 4 �. Y EH 1426