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W I! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 fist' ,.:. .l -#s, .' "'• -? �^: '.r ti' .:'.,� ' f '.1,„ a. �: � � PERMIT EXPIRES'IlYEAR FROM DATE ISSUED .(Complete in;Triplicate) ...,f., . Application'is hereby shade 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. 11 ' r Job Addressf`ir � �.,. I City Lot Size" ¢cr�,f PM -Owner s Name -Pe C'ej ERthI "Address _2� II'TCl<"pl/C[ S' Phone [ � Contractor 60 w l � )C*- Address Licel se No. l? _��Phone TYPE OF WELL/PUMP: I� NEW WELL _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALL TI N Ll SYSTEM REPAIR OTHER L1 DISTANCE TO NEAREST: SEPTIC TANKO�1*---SEWER LINES DISPOSAL FLD. PROP. LINE f :.— FOUNDATION AGRICULTURE WELL OTHER WELL-_ PITS/SUMPS_ INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICillfiNS ❑ Industrial ❑ Open Bottom ' Manteca Dia. of Well E. a.. n Dia. of Well Casing `tel XDomestic/Private Xralvel Pack ❑ Tracy Type of Casing Specifications 160 4P ❑ Public ❑ Ot�lher ' Ll ea Depth of Grout Seal Type of Grout h I�4P El Irrigation —{�FAF pprox.`Depth ❑ Eastern Surface Seal Installed by L2&n"4y_ Repair Work Done ❑ Type of Pump H.P. State Work Done 'Well Destruction ❑ Well Diameter Sealing Material (top 50') Ed4/9G O DepthFiller Material (Below 50') T OF SEPTIC.WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No'septic system permitted if public sewer is available within 200 feet.) Installation will s as rcial_ Other Number of living units: ��fbooms Character of soil to a depth of,3 feet: `' __ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.' Compartments i PKG. TREATMENT PLT. ❑ Methbd.of Disposal w i Distance to nearest: Well ' Foundati Property Line '' -f " LEACHING LINE I] No. & Length of lines Total length s FILTER BED ❑ Distance to nearest:. Well Foundation Property Line ------------------- SEEPAGE PITS ❑ Depth j: Size Number SUMPS .- ., L1, Distance to nearest: ---Well Foundation Property Line - R' 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. 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 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 call for all re �it inspections. Complete drawing on ra rse side. Signed X o Title: Date: } FOR ARTMENT USE ONLY r Application Accepted by Date 7 Area S Pit or Grout Inspection by Date.301? Final Inspection Date/ t . Additional Comments: F ❑ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca. 823-7104 ❑.Tracy 835-15A5 Applicant- Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O.:Box 2009, Stk., CA 95201FEE t. INFO AMOUNTiDUE +� AMOUNT REMITTED CK 4 CASH RECEIVED BY s PATE PERMIT'NO. I +-EH 13-24(REV. r. F EH 14-28