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APPLICATION FOR PERMIT j SAN JOAQUIN'LOCAL'HEALTH DISTRICT a 1601 E.�. HAZEL T ON_ AVE., STOCKTON, CA V '� Telephone {209} 466-6781 PERMIT EXPIRES` YEA ''FROM DATE ISSUED-' ' �,=.3: s fnjtst. r�i (Cornplete rn Triphcate)r `{ �" 1 - '. I;y.. I`�t 4 w.'i.r r s..•i., i - c ,4a �. .«.c „:."s -!btiita' v ' 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 R 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. ' v+t� s:, ;:i at: . 9.- �, �ti Job Ad ! dress � s '``'meq, i pt";'; s7�6.1., PM Owner's Name dAd s`s Phond e 1 -- ? Contractork ! 4/ L Address �� t` M License'No. Phone Y TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEM NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-1] OTHER ❑ DISTANCE TO NEAREST:tSEPTIC TANK SEWER LINES - ' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia.;of Well Excavation El Domestic/Private El Gravel PackDia. of Well Casing ` - ID Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of,Grout Seal i ❑ Irrigation Type of Grout 9 ---Approx. ❑ Eastern Surface•Seal installed by Repair Work Done ❑ Type,of.Pump H.A.- y. " -State Work Done Well Destruction ❑ Well.Diameter _ Sealing Material (top 50') Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION ❑ DrESTRUCTI;ON4 iNo septic system permitted if public sewer is i f "" ilable Within-200 feet.) Installation will serve: Residence Corrimercial, Other _. Number of living units: Number of bedrooms ' s ir . Character of soil to a depth of 3 feet:/' SEPTIC TANK.— Water table depth VType/Mfg-, Capacity"� No. Compartments ' PKG. TREATMENT PLI' ❑ i' .r Method of Disposal Distance to nearest: Well Foundation-Z"� .Prapeity Line----� LEACHING LINE ❑ No. & Length of lines - - N. Total length/size'" FILTER BED ❑ Distance to nearest: Well Foundation'- .i Property Line . , -7— SEEPAGE PITS` - ❑ Depth y - ISize x f r Number k SUMPS ` ❑ i Distance to nearest:_ Well Foundation DISPOSAL PONDS ❑ _ Property Line 1 r I hereby certify that I have prepared this application and that the work will be done tri 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"performarice 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 certify that in the performance of the work for which this'permit is issued,I_shall employ Von laws of California." r persons subject to workman's compensa- The applicant must call for all required in specti S. Completedrawing on revers side. Signed a -t ,rI Title'` Date: �OR DEPARTMENT USE ONLY •� Application Accepted byv r�! Date Pit or Grout Inspection by C r' , .;Dated Final Inspection by E Additional Comments: - St 466-6781 ❑ Lodi 1369-3621'& 0 Manteca '823- 7104 ❑_Tracy 835-6385.—' �.. Applicant Return alf copies to.. Emironmerrtal Wsaa1#ii Permit/services 1601E Haietton Ave., P.O. Box 2009, Stk., CA 36201 �* S ! fNFO AMDUNT_3DUE AMOUNT,REMITTED CK RECEIVED BY m 5 CASH DATE PERMIVNO. 1 +EH 13-24(REV.l _ r EH 14-26 k Z6 ez&