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.0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 6gw 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 MOP PERMIT EXPIRES 1'YEAR FROM DATE ISSUED {Complete in Triplicate) 41 p�7 k 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 ump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllp f Local Health District. r 4 (/�/. s*Aof Size JT.r PM I ob Address � City LJ { a � �� I Phone 4 III � Owner's Name �ro��-.– Address —.--� *- I ('CI)ntractor #" Address ' License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ " DESTRUCTION E3 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ : OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial El Open Bottom C3 Manteca Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private [] Gravel Pack ❑ Tracy Type of Casing Specifications l'1 Public F Other ❑ Delta Depth of Grout Seal Type of Grout - t. - 1 Depth t I Eastern ' - ` I i Irrigation —.-Approx. Surface Seal Installed by� t. 14 Repair Work Done ❑ Type of Pump ! H.P. State Work Done _ Well Destruction ❑ Well Diameter j Sealing Material (top 501 Depth Filler Material (Below 501 PC TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i_I DESTRUCTIO (No septic s st m rmited if public sewer is eet Installation will serve: Residence° Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line f - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I 1 Depth Size Number (1 I .'_x.1N - U SUMPS L1 Distance to nearest: ell� Foundation Property Line DISPOSAL PONDS ❑ r 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 Dislfict. Home owner or licensed agent's signature certifies the following: ;'I certify that in-the pe,rformance 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." j The applica ust cali for all required inspections. Complete drawing on reverse side. l./ 7 Signed X� ��___ � Title: L&rnleN Date: FO DEPARTMENT USE ONLY Application Accepted by Date_ Area / Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO ("� �( '7 Cep + EH 13-241REN.i/H5) INFO UQ �,t V O 1 _2 a6 EH 14-26