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~ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., 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 �h r `�,_N w�/ n C�� ACS city Lot Size 3" '91 M 0 Owner's Name Address r� Phone Contractor CU k ddress M('l License No. CJ I Phone L TYPE OF WELL/PUMP: NEW ELL WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION i SYSTEM REPAIR El OTHER 1:1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 11!:15DISPOSAL FLO, 0_! .' PROP. LINE -00 L FOUNDATION ,— AGRICULTURE WELL U E OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casin �9 Ll industrial El Open Bottom El Manteca Dia. of Well Excavation _ g — L S''�/L� Specifications �omestic/Private �t-Gravel Pack El Type of Casing �� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 5 C z Type of Grout gcw re kf(J ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by (� Repair Work Done ❑ Type of Pump H.P. _ Stale Wofk Done � � I7 Well Destruction LI Well Diame r >--4`— Sealing Material (top 50') (� Depth C/DFiller Material (Below 501 �J TYPE OF SEPTIC WORK: NEW INS ALLATION ❑ REPAIR/ADDITION Ll DESTRUCTION ❑ allo septilablec systthin m emitted if public sewer is eet Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well iPoundation Property Line LEACHING LINE ElNo. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number - SUMPS ❑ Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS 17 F 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 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'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 call for all required inspections. Complet awing on reverse side. /{�/� R Signed X� �� Title: �' �� "—s Date: FOR DEPARTMENT USE ONLY �7 Application Accepted by � -- Date r" Z`t`r3 v Area V Pit or Grout Inspection by r %� ate_ Final Inspection by/ J 211 � Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 )(Manteca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental Hea h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ffF!AMOUNT DUE AMOUNT REMITTED C fi) RECEIVED BY DATE iERMIT NO. a EH 13 241REV. 1O� EH 14-26