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-tea APPLICATION,FOR PERMIT SAN JOA L -- ' OUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL-10N AVE., STOCKTON, CAIs f Telephone (209) 466-6781 JAN•2 QL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . ,Y.. Vete in Triplicate) �!' � � i l-NVIROMENITAL HEALTH (Comp PPERMIJ,/ �W, '46plication is qyF 1 County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rule and Regulations of the San Joaquin Application is hereby made to the SanCJoagrin Local Health District for a permit to construct and/or install the work herein esC i e fiance with San Joaquin !r w.-, made in comp �rz ., - Al ., < Local Health Disktri�c�t -: jo�[.�r2s `"- ' - " r �„yy n Q Lot Size PM -- rLQo FC City /IV y .:.- job Address 1 - - t l C I! Phone Addresses Owner's Name *? e ✓]. a0A Or € License No.c2 7 - phone Address A11 Contractor �1 L WELL REPLACEMENT DESTRUCTION F1❑ NEIN WEL TYPE OF WELL/PUMP: SYSTEM REPAIR [IOTHER :1PROP. LINE�a - PUMP INSTALLATION DISPOSAL FLD. -�--� SEWER LINES � w DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS l FOUNDATION AGRICULTURE WELL TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing G INTENDED USE L1 Manteca Dia. of Well Excavation o Industrial ❑ Open Bottom Type of Casing Specifications f <Gravel Pack ❑ Tracy 7 Q� Type of Grout Q { (� Domestic/Private ❑ Delta Depth of Grout Se aj ❑ Public ❑ Other I __—Approx. Depth ❑ Eastern H.P. Sur�ac� Seal Installed by � ❑ Irrigation State Work Done q, � A 2 Repair Work Done [-1Typeof Pump �(J - d - Sealing Material (top 50'1 i = Well Destruction ❑ Well Di et�eA� Filler Material (Below 50'} Depth permitted if public sewer is available within 200 feet.),TYPE OF SEPTIC WORK: NEW INS7ALLATlON ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic sy em i Other�� a ti, Commercial Installation will serve: Residence Number ofliving units. Number of bedrooms Water table depth Character,of soil to a depth of 3 feet: 6 Capacity No. cqU partments SEPTIC TANK 'bI ❑ Type/Mfg _ - Method`of Disposal PKG. TREATMENT,PLT.❑ Foundation Property Line Distance to nearest: Well Total length/size LEACHING LINEO� No. & Length of lines property Line�— �-� Foundation�- (� FILTER BED i :. x 71 Distance to nearest: Well Size Number SEEPAGE PITS ❑ Depth Foundation Property Line r SUMPS :❑, Distance to nearest:. Well ❑'� DISPOSAL PONDS t I 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, an L rules and regulations of the San Joaquin Local Health District..., I certify that in the performance of the work for which this permit is issued, I shalt/not Home owner or licensed agent's signature certifies the following: " Bosons subject to workman's signature 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 P tion laws of California." I. i The applicant must call for all re jred inspections. Complete drawing an reverse side. Date: Z Title:'` SignedX ;� _ FOR PEP RTMENT USE ONLY e77 J Date Irl Area Application Accepted by Date Z69ZDatFinal Inspection by — Date Pit or Grout Inspection by .. �: • � Additional Comments: ❑ Lodi 369 3621.#. ❑ Manteca 823-7104 --Q•Tracy-635-6385 Stk., CA 95201 [Ii Stk 466-6781 n Health PermitlServices 1601 E. Hazelton Ave., P•01B Applicant- Return all copies to: Environmental ox+ r RECEIVED BY f DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH P- I INFO 2� 00�- 1 L + EH 13-24(REV.I/n 5) -- EH 14-28 --