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�atl� r � Y 1�IgR®t i ' "1r'Y.f 'T �rv� * --�'' e• 4 � J_' ` "�\_, ?,r�.. t.�..z'k„A: APPLICATION FOR PERMET F �. SAN JOAQUIN LOCAL-HEALTH DISTRICT x _ 1601 E. HAZELTON AVE. STOCKTON CA ` Telephone (209) '466-6781 '�• L - .. PERMIT EXPII4ES 1-YEAR FROM.E?ATf ISSUED "r --[Complete in Triplica':e} : •1 t:r � c ,f,;`s rAppltcatron_is hetelnr made to the Sari Joaquin Local Health District for a permit to cor struct and/or install the work heratn descriCed.`Titia application rs ` I Q ¢ a>y`�"made in ca;gAance with San Joaquin Counry Ordtnanee Ne.549 for sewage or No.:18fi2 for we11lpump and the Rules and Rtsgu4ttiotq of the Sdn Joaquin ti v tt --Local Health_Distrrct -^t' -:=� s y y6 Job AddressCitY -`•"Cot Sha PM r s rv" -tet t c b� v f Owners Na a Address 5 p+ Phone Q _ r l ��, •: r_ G.j " C�Address Conttacd'� License No.�Phone t ttx ` TYPE OF WELL/PUMP:. NEW WELL ❑- WELL REPLACEMENT ❑ _ DESTRUCTION ❑ 7^ 'MPUMP INSTALLATION ❑ SYSTEM REPAIR OTHER fl" DISTANCE.TO NEAREST SEPTIC.TANK-' SEWER LINES DISPOSAL FLD PROP LINE h c sj r FOUNDATION AGRICULTURE WELL OTHER.WELL PITS/SUMPS � _INTENDED�USE TYPE OF WELL PROBLEM AREA .CONSTRUCTION SPECIFICATIONS '{ r s ❑ Industrial = O Open Bottom._ ❑ Manteca Dia.of,Well Excavation Dia.of Well Casing E rf ? Domestie7Prlvate ❑ Gravel Park Cl Tracy Type of Casing Specifications > ¢ {a< f rF n Public f'1 Other. ❑ Delta Depth of Grout Seal Type of Grout_____ -x r Gi i} t l lrrigatton _ Approx.-Depth t I Eastern Surface Seal Installed by I' s fi! Repair Work Oona. Type of Pump H.P. '' /� State Work Done , L � Weil Destruction ❑ :Well Diameter Sealing Material{top 501 AJ x Depth Filler Material(Below 501 ' 2 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDtT10N I I DESTRUCTION t I (No soptie system permitted if public sewer is Tks available within 200 feet.1 f I -Instaflation.will serve ' Residence',.. Commercial_, Other ra 4Lx Number of liwng units: Number of b .!rooms Character.of soil to a depth of 3 feet:' _Water table depth F SEPTIC 1ANK I� TypelMfg Capacity No Compartments r PKG.TRFATMENT.P T. a . Method of Disposal : f 3 Distance to nearest: Well Foundation Property bine ,. LEACHING LINE' !❑. No.& Length of lines Total length/sire v+ FILTER BED' 0 Distance to nearest: Well_ Foundction Property Line ? J SEEPAGE PITS 1 I Depth Site � _ Number_ s }i SUMPS LI 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 ataWlews and; %.�f. rules and regulations of the San Joaquin Local health Dhtrict. r i $s Home owner or licensed agnn!'s signature certifies the tollovhng:"I certify that in the performance of the work for which this permit is issued,11 shall not employ any parson in such manner as to become subject to workman's compensation laws o1 California."Contractor's hiring or sub,-contract' wgnntura , r, certifies the following:"1 certify that in the performance of the work for which this permit is issued.I shall employ persons subject to workman's rnpensa tion laws of California." The ap m call for all requ' inspe ons. Co plate drawingon r e side. c 3 to Signed X Titte: _SP Date: r - FOR DEPARTMENT USE ONLY L Application Accepted by 4' ', -- Date_`�.___.:__ Area i II Pit or Grout Inspection by Date-_ Final In,pection by'rC'_- Date a s / l - - _, i✓ . Additional Comments: ❑ Stk 486-67(!1 , El Lodi 369.3621 Manteca Ei23J104 ❑Tracy 835.5385 J. Applicant• Return all copies to: Environmental Hoatth Permit/Services 1601 F. Hazelton Ave., P.O.Box 2009, Stk., CA%201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY pA7[ PERMIT N0. , ? INFO CASt1----I E 1 N H 137 1 kY - L' y L r- IIB-1'