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i! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781: i PERMIT EXPIRES 1"YEAR FROM DATE ISSUED ' (Complete in Triplicate) i 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. 1.862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address _A _(o _ t v City J& to U 0 Lot Size PM .Owner's Name Address ^' 2 Phone Contractor eta, Address License No. Phone_ TYPE OF WELL/PUMP: NEW- ELLS �,.�..WELL REPLACEMENT" ❑. 'DESTRUCTfON ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR 01, k ,. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. a PROP- LINE FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS} �❑ Industrial ❑ Open Bottom la .G�Manteca." _Dia-of Well Excavation Dia. of Well Casing ❑ Domestic/Private E] Gravel Pack i t ❑ Trac Type of Casin j.b . i, y yp ! g Specifications I'] Public ❑ Other "fi ❑ Delta Depth o[ Grout Seal �R u 'f' Type of Grout I I Irrigation —_Approx. Depth i I 1 Eastern Surface Seal Installed by - } Repair Work Done ❑ Type of Pump Ai - f H.P, State-Ww.kiDone 1 Well Destruction ❑ Well Diameter: Sealing Material (top 501 V Depth Filler Material (Below'91 TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION I I DESTRUCTION I 1 lNo septic system permitted if public sewer is availablewithin200 feet.) _( , Installation will serve: Residence X Commercial_ Other Number of living units: _ ' Number �edroo Character of soil to a depth of 3 feet: Va Water table depth SEPTIC TANK Type/Mfg — - 'CapacityA'G }, No. Compartments PKG. TREATMENT PLT. ❑ :i x ;! jN t t! Methodlof Disposal P Distance to nearest: dell Foundation 0 iProperty Line 1._�_ LEACHING LINE Ij., ❑. No. & Length oflines Total length/size f7Q FILTER BED Distance to nearest: " Well Foundation Property Line_ SEEPAGE PITS I I Depth # Size _ Number SUMPS L 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 Locals Health District. ~_" _ t 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." 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 must calf for all required inspections. Complete drawing on reverse side. Signed X \>a (,;� r i Title: date: V all T- MENT USE ONLY Application Accepted by rl'o � ZLDate rea fy r Pit or Grout Inspection by I Date Final Inspection by -?–r? Date �s Additional Comments,. / ❑ Stk 466-6781 ❑ Lodi 369-3621 it ❑ 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 OUNT DUI: AMOUNT REMITTED INF CK H RECEIVED BY rr77 6ATTE PEitMIT"N/0�.EH 7 + EHt42giREV.t/fa51 -76eV� �� j !/ R 1