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-�—— APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT {] 1601 E. HAZES ON®AFVE., 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.}�} ��" Job Address ilfiOa ! I?Drn Ci Size PM Owner's Name 1 ' ` AddressL7 j T._.-._-�P�-s 1 V? _ Phone Contractor dress License No. Z3 Phone_ P V TYPE OF WELL/PUMP: NEW ELL Q� WELL REPLACEMENT ❑� DESTRUCTION C�-� PUMP INSTALLATION SYSTEM REPJIR ❑ OTH�R ❑ j DISTANCE TO NEAREST: SEPTIC TANK A140 ' !t SEWER LINES 9V + DISPOSAL FLD. 4 ')"'PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— SAO PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUOTiON SPECIFICAT ONS ❑ Industrial ❑ Op Bottom ❑;Manteca Dia. of-Well Excavation Dia. of Well Casing omestic/Private ravel Pack ❑ITracy Type�bf Casing ` Specifications M Public ❑ Other F1lDelta Depth of Type Type of Grout I I Irrigation �Approx. Depth I Ea errr 5u�face'Seal Installed by / _ Repair Work Done ❑ Type of Pump _1 f .P:'I �---' f state Work pone -01 Well Destruction Well Diameter -Sealling Material„Itop 507) { Depth i_ iF'ller Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I f.: R�PAl ADDITION t.I DESTRUCTION-lkl,(No septic system permitted if public sewer is �') available within 200 feet.) Installation will serve: Residence_ Commerc#al Other +�" r? Number of living units: Number of bedrooms ' . Character of soil to a depth of 3 feet: t - Water table depth SEPTIC TANK ❑ Type/Mfg � Gapacity�. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ^" Distance to nearest: Well Fo,ndati+ � Property Line LEACHING LINE ❑ No. & Length of lines R �' Total lengtFi/size FILTER BED ❑ Distance to nearest: ; Well v /f Foundation Property Line t SEEPAGE PITS l I Depth I Size Number SUMPS L1 Distance to nearest: i Well Foundation Property Line DISPOSAL PONDS ❑ i 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 regulati an Joaquin Local Health Distiict. I Home owner icensed agent signature certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall not employ any arson in such man r as to Dec m subjectf orkman's compensation taws of California."Contractor's hiring or sub-contracting signature 4 certifies t following: "I certif at in t c f f e wor r which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of Californi The appl ant o 11 req 'e plate rawing Signed X � e/ Title: Date: Uw j DEPARTMENT USE ONLYAO/I �r Application Accepted by Date /7 Area Pit or Grout Inspection by Date Zcl h;6 Final Insp ctio by ' Date r Additional Comments: ,, ❑ Stk 466-6781 ❑ Lodi 369-3621 OkManteca 823 ❑ Tracy -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMITNO. I INFO 1 i.EH 13-24(REV,1/s 5) EH 1628 `