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ce APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT w 1601 E. HAZELTON AVE., STOCKTON, CA I �( Telephone (209) 466-6781 3 � 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 Local Health District.. /S- / J E-- City "" Lot Sizec' PM Job Address Owner's Name (,(�/4/LO� — Address ! �� A-"� l�"' Phone 31 5"'719 Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER d DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEy FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications Type f'l Public n Other Cl Delta,�� Depth of Grout.Seal of Grout — I I Irrigation ' —_Approx. Depth I I Easterner Surface Seal Installed by - Repair Wo4k Done 11 Type of Pump H.Pt, �p State Work Done Well Destruction ❑ Well Diameter Sealing,Material (top 50') j Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1,1 REPAIR/ADDITION l.l' DESTRUCTION I I (No septic system permitted if public sewer is fi` t available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: � r �H Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments . PKG. TREATMENT PLT. ❑— - Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tiJ nearest: Well Foundation Property Line SEEPAGE PITS I AI Depth Size Number' SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statJand 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 issuedemploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractin 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 a ornia." kr}b c The applica ust call for all r i d inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY jApplication Accepted by Date �^ �A x�Area Pit or`Grout Inspection-by --- - Date Final"InspectionTby— ' Date Additional Comments: P57<rI I ❑ Stk 466-6781 ❑ Lodi 369-3621 e4hanteca 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 INFO AMOUNT DOE AMOUNT REMITTED CASH ,►M'RE+CEIVED BY DATE PERMIT NO. +.EH 13-24(REV.185) 1 V �` �J'�J ROW ! , ' q'Y-1 -CYO `� EH 14-26 E