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' • r 4 rL APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON AVE., STOCKTON, CA Telephone 12091 466-6781 C PERMIT EXPIRES VYEAR 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 k 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. /9--Fvo f=U. //" } Job Address O �AR , ' ` NiR City -MI Lot Size Owner's Name �� ^' p Address 11800 .Nl Phone 10 Q Woot)LftoI r rr--ii p� -56� Phoney 1 a � l Contractor W� �� - _Address License No, r TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 51oli►VAt QRU S DISTANCE TO 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 ❑industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic IPrivate ❑ Gravel Peck El Tracy Type of Casing Specifications M Public �Olther .(Delta Depth of Grout Sear Type of Grout -. ^� I I Irrigation �.Approx. Deptfi I I Eastern Surface Seal Installed by ! Repair Work Done ❑ Type of Pump H.P. State Work Dona E r Well Destruction ❑ Well Diameter a- Q Depth Filler Material 4 ': TYPE Of SEPTIC WORK: NEW INSTALLATION l7 REPAIRIADDITION I 1 DESTRUCTION I I lNo septic s stem permitted if public sewer is available within 200 feet.t Insiaiatibn call!serve: Residence T Commercial_ Other Number of living units: Number of bedrooms i Character o1 soil to a depth of 3 feet: Water table depth k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. B Length of lines Total length/size FILTER BED tj)Ipi ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number ' SUMPS 141/46 0 Distance to nearest: Well Foundation Property Lind DISPOSAL PONDS ❑ 1 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 e 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: "1 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 applica=M? t 1 required inspections. Complete drawing on reverse side.Signe � Title: exay, bn6hNM 6Fff=. Date: FOR DEPARTMENT USE ONLY i Application Accepted by A;1 1iQr1i — Date Area 4 S Pit or Grout Inspection by Date Final Inspection by ?" ` no Data—10 4 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 359-3621 Manteca 823-7104f ❑Tracy 835.6385 Applicant...- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton AvB„ P-O.'Box 8M281 FEE AMOUNT DUE AMOUNTHEMITTED as RECEIVED BY DATE PERMITNO. INFO I • EH1a-24IREV.iiw6� EH 1428 r" f