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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 } 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. 1E162 for well/pump and the Rules and Regulations of the San Joaquin i Locai Health District. j Is& - r C•{ Lot Size�u� <� PM ' Job Address r7 City % Owner's Name �-� -S Address � � ,' Phone . 73 e--•--�------^` ""ter°" - -' '. . �,�,--.--.,�.-,. Contractor �� ' Address l License No. Phone ` TYPE OF WELL/PU P: '- '� ...,, WELL L1 WELL REPLACEMENT DESTRUCTION 1 i PUMP INSTALLATION XSYSTEM REPAIR (7OTHER'❑ r °I I 'DISTANCE TO NEAREST: SEPTIC TANK `_ _ SEWER LINES DISPOSAL FLD. PROP. LINE"'D FOUNDATION, AGRICULTURE WELL ri�nt° OTHER WELL PITS/SUMPS Ln INTENDED USE TYPE OF WELL PROBL£M`AREA CONSTRUCTION SPECIFICATION_ �L p ❑ Industrial'�"""��""" "Open Bottom'; +171 Manteca i Dia. of W611 Excavation Dia. of Well Casing Domestic/Private 171Gravel Pack `,,❑ T•racy t j Type of Casing ee_' Specifications - %-_i i`1 Public -F) Other F1 Delta,t , El Depth of Grout Seal Type f grouts � e+t� 1 1 Irrigation � �._Approx. Depth f1 I Eastern I� Surfaca Seal Installed byQ Repair Work Done ❑_ Type of Pump S Llh % H.P.-3 State Work Done Well Destruction Welf Diameter f�l `�Sealing Material (top 50'1 h `-� Depth ti�.r? '� t - Filler Material 18elow 50'1 �4 fh TYPE OF SEPTIC WORK: NEW INSTAL•L-ATION-h)—REPA�lR�A'DflITION E]—DESTRUCTION t I (No septic system permitted if public sewer is �Yr available within 200 feet.) 4 �Ihstallation will serve: Residence— Commercial_ Other. (� ' Number of living units: Number of bedrooms 4 t Character of soil to a depth of 3 feet: .-'Water table depth— SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ �'�.. ' Method of Disposal s Distance to nearest: Well Foundation Property Line- LEACHING LINE ❑ No. & Length of lines t, LTotal Iengtfi/size .FILTER BED ❑ Distance to nearest: Well i Foundation Property Line } SEEPAGE PITS I i Depth Size �'* '. Number ^ SUMPS Ll Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS ❑ t - i ,I hereby certify that I have prepared this application and that the woik will be done'in accordance with San Joaquin county ordinances, state laws,and rules and regulations of the San Joaquin Local Health Diltrict. 1111: '4 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 taws 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 mu t call for all Tred i spections. Complete drawing on'reverse side. I Signed X Title: �C"C_-/ Y/ -_� Date: FOR DEPARTMENT USE ONLY �� Application Accepted by Date_. Area . tS S ✓� Pit or �t Inspection by� Date� Final Inspection by Date 3 Additional Comments: \ n� U ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 7104 ❑ racy 835-6385 �LNv� i r\o x�� Applicant - Return all copies to: Environmental Health Permit�/Se� es 1 E. Iton Ave., P.0 Box 2009, Stk., CA 95201M1a�J FEE AMOUNT DUE AMOUNT REMITTED `� CASH RECEIVED BY DATE PERMIT'NO. INFO _ �.EH13-21IREv.tix51 1��JJ P r -7 _�,�� EH 14-2e 1 l t� r