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- . . . . . . . . APPLICATION FOR PERMIT Y 'SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZELTON AVE.,-STOCKTON, CA 'Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED., {Complete-in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.'`This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin " It Local Health District. r l � R.? • City �z 'C v FLot Size /`" � 31A Job Address P � i 4 - Owner's Name — X51"�` ..r Address - Phone Contractor ` Addres's lfr4$L l Gf:Q __License No. ' Phone F TYPE OF WELL/PUMPi »ti 9'N EW WELL,0 WELL REPLACEMENT ❑ DESTRUCTION ❑ P0MP-,INSTA'LLATION ❑ SYSTEM REPAIR L3j OTHER EJ DISTANCE TO NEAREST- SEP.TIC"TANK,' - SEWER LINES DISPOSAL FLO. PROP. LINE ` .FOUNDATION - AGRICULTURE WELL OTHER WELL , PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A�__.,, ❑ Industrial El Open Bottom 0 Manteca Dia. of Well Excavation Dia. o{Well Casing ► �I ❑ Domestic/Private Q Gravel Pack F ❑ Ti-ecyWType of Casing Specifications 0 Public 0 Other j D:Qelta Depth of Grout Seal Type of Grout 1, ❑ Irrigation L—Approx. Depth 1,°El-fastern .. Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State"Work Done l� Well Destruction 0 Well Diameter '� a" `- 5ealing Material-Itap 5d'1" 1 V Depth Filler..Material (Below 501 TYPE OF SEPTIC WORK: "NEW INSTALLATION REPAIR/;4D-DITION ❑-+DESTRUCTION ❑ 4No septic system permitted if public sewer is x }� r, t availableawithin 200 feet.) Installation will serve: Ri sidence Commercial_ Other It i "+ Number of living units: Number of bedrooms _ R r�"�-- Character of sail to a depth of 3 feet: Water table depth a SEPTIC TANK • Type/Mfg R.i-Ll Capacity it Nol Compartments PKG. TREATMENT PLT. ❑, t o �- Method of Disposal Distance to nearest: Well Foundation• Property"Line L7 t t F F LEACHING LINE No. & Length-of linesNotal length/size I t FILTER :BED f, ,�"❑.,,Distance to nearest: .:Well .Foundation --k 'Property Line t r �/ ; � EE6AGE`.rPITS ❑' Depth !Q dC' _S ize SUMPS _ Distance to nearest: Well. ouil�lation A- F� -Fioperty Line DISPOSAL PONDS zLJ 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-Jpaquin Local Health District.,. _ " - ` i i." I - s Home owner or licensed age'nt's'signati re:certtifies the following: "I certify That 1n the pe!Armanceiof the work for which this permit is issued, I shall not em -As..--ddgy person;in such manner as tobecome:subject.to workman's-compensation. ofi•Califomia:" Contractor's hiring or sub-contracting signature certifies'the following:"I certify that in the performance of the work for which this peenilf is issued, I shalhemploy persons subject to workman's compensa- k *tion laws of California." °, I ' The pplicant must call for all r fired pec ions. Complete drawing on reverse side. Signed X a Title: �1 f Date: kAp 1�47 FOR DEPARTMENT USE ONLY Application Accepted by y Date Area I . Pit or Grout Inspection by � Date Final Inspection by Date ^ Additional Comments: t 1-1Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 +1 > ` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. H zelion Ave., P.O. Box 2009 Stk., CA 95201 y z, - - --FEE AMOUNT DUE AMOUNT REMITTED •CK RECEIVED 8Y SATE PERMIT'NO. ...�r--:--•-�-.o--..,-" INFO CASH '+ EH 13-24,1 REV. 5) �- EH 14-28 .