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i u APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA I� ! Telephone (209) 466-fi781 PERMIT EXPIRES T 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. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. ` PM ' l ,V', Fl Y� 1 City Lot Size Job Address Q 1 -S A ? C?� Address Phone 9-�S-1 Owner's Name I _ p©, ,� ' [� i }Address License No. � �z�l% Phone ContractgeAl C� u TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ri I. DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E3 industrial t ❑ Open Bottom L] Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout — 3: I i Irrigation —,Approx. Depth I i Eastern Surface Seal Installed by - y p. State Work Done Repair Work Done El Type of Pump � ."e Well Destructs p ❑ Well Diameter Sealing Material (top 50.1 e1 _ 1.( Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I -DESTRUCTION-(-1-INo�septic system permitted if public sewer is y -11 available within 200 feet.) Installation will serve: Residence X Commercial_ Other a �, I , 3 'r Number of living units: Number of dooms Gheracter of'soil to a depth of 3 feet: Water table depth Q SEPTICTANKI k Type/Mfg �-� Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposalr 1 - ",Distance to nearest: We JIB Foundation Property.Lin I' LEACHING LINE >( -,No. & Length of lines ' y0 Total length/size too Ya ' r � `FILTER BED ❑ 'Distance to nearest: Well-1(X:._ Foundation PropertQ ine l A r9 Size Number I SEEPAGE,PJTS V� DePth r� SUMPS Cl i,Distance to nearest: Well IFoundation .__— Property Line — SI. t� DISPOSAL PONDS Cl 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 1 I 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."Contractor sshifing or sub-contracting signature p certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ.per§anssubject to workman's compensa I tion laws of California.'- 1€ The applicant mus ^fall for all r$(�uir@I inspections. Complete_drawing on-reverse side. .yr Qt I I19.!`,U\ iif'! - -- - Date: Signed Title: 1 FO DEPARTMENT USE ONLY / Application Accepted by i^ — Date Area �-- i or Grout Inspection by te�-� Final Inspection by Date/� I At i i Additional Comments: ❑ Stk 466.6781, ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 CK it„y 'I FO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE MPERMIT'NO.vF � ,EH 1324IREV.t/R5) g EH 14-26