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E. S. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT No k)jcU- 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 -4r-NO \0P-t- C Ll WZ Q PERMIT EXPIRES 7 YEAR FROM DATE ISSUED �Y olt (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 Local Health District. Com( 7 cc��-Tde.J !73-r��-//' Job Address 3 � E. / ! City? eToet Lot Size J PM Owner's Name +C �-- Address `� 3 1 �-- Phone Contractor Address License No. Phone TYPE OF WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP 1N'S'f•A LATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA PRQP. LINE FOUNDATION CULTURE WELL ER WELL PITSISUMPS INTENDED USE TYPE OF WELL :P!ROBLEM AREA UCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom MantecaDia. of xcavation Dia. of Well Casing ElDomestic/Private C1Gravel Pack y Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _ — . Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ ITlve of Pump H.P. State Work Done Well Destruction e Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 f'' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 Local 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 become subject to workman's compensation laws of California."Contractors 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 must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: Z C]—� DEPA NT USE ONLY Application Accepted byData Area Pit or Grout Inspection b De Final Inspection by Additional Comments: �&6321 �0 �ManteurLa�710�4 ❑ Stk 466-6781 ❑ Lodi ❑ Tracy 835 63$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REV.I/e5) EH 14-28 i