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9 k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E (Complete in Triplicate) w y Application is hereby made to the Sari 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.. [ f Job Address City Lot Size -�� PM Owner's Name 7�;z" 13,EaP Address Phone Contractor [iG: iv Address O C' 76 n License No Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ '_+ ` SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS X1111 i INTENDED USE TYPE OF W�L�. i:_mPRdBL"EM AREA,,, CONSTRUCTION SPECIFICATIONS (� ❑ Industrial ❑ Open Bottom EI-Manteca Dia. of Well Excavation Dia. of Well Casing ! V -, El Domestic/Private '171 Gravel!Pack ;# *I] ac Try' f" Ty4S of.Casing Specifications (`1 Public ❑ Other ," [l Delta Depth of Grout Seal Type of Grout _. ' I I Irrigation i _Approx Depth ( I Eastern �L Surface Sea! Installed by '- �• Repair Work Done ❑ Type of Pump H.P- State Work Done _ y j Well Destruction ❑ "Well Diameter Sealing Material (top 501 - 4 Depth f+ Filler(Material (Below 501 TYPE OF SEPTIC,WORK:' ANEW INSTALLATION/` REPAIR/ADDITION I I4 DESTRUCTION I I (No septic system permitted if public sewer is 1 ."i available within 200 feet-) ! Installation will-serve: Residence^ZCommercial_ Other Number of living units:;,1 Number of bedrooms Character of soil to a depth of 3 feet: _7 Water table depth SEPTIC TANK ' i TypePMfg i .� Capacity gee tT -t1 No. Compartments PKG. TREATMENT PLT.'❑ , ,LLa; ? - t- ' , 4'-Method of Disposal / t`.f Distance to nearest: _ Well I"p' Foundatipnf Property-Line L - , LEACHING LINE";: r No"4 Lengttf of)4ines,._.___vim_-._ T y C-4"_,7otal`lengtKAiie FILTER BED i Q0'SDistance,to nearesi:,s Well Foundation -r- Property UrLo % ' "!"?`' SEEPAGE PITS f I'' Depth i Size Number SUMPS Cl M{Distance to nearest: Well Foundation. ' Property Line 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 vocal 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 bac'bme'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-_s1 l(employ persons subject to workman's compensa- tion laws of California." ' The.applicant must call for !1 required-inspections:-Complete'-drawing on-reverse-side:l~ Signed X ' Title: /t.��.�--cam_.! x ____ __ Date: k a O PARTMENT USE ONLY �:4 R Application Accepted by Date ( oe Area 4113 t / Pit or Grout Inspection by Date Final Inspection by Date' Additional Comments: -- ❑ Stk 466-6781' 1] Codi 369-3621"� ❑ Manteca' 823-7tO4 ❑ Tracy' 835-6386 i l Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA 95241 A., r FEE AMOUNT DUE AMOUNT REMITTED CK-CASH RECEIVED BY--_r DATE -PERMIT'NO. l n M.., >s• a. INFO EH'13=24'IAEV:riK51 EH 14.26 f:r: