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APPLICATION FOR PERMIT _..' —D3y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I 1 Appl (Complete in Triplicate) ication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This Local H compliance with San Joaquin County Ordinance Na.549 far sewage or No. 1862 for well/pump and the Aides i Local Health District. tappfica and Regulations of the San Joi� Job Address ; ,s City Lot Size \ Owner's Name ��lir� � PM \ Address _� � "� ------.._._ Phone Contractor �� TYPE Ol WELL/PUMP: Address NEW WELL " --License No_ Phorre- WELL RE,LACEMENTa� DESTRUCTIONI3 PUMP INSTALLATION DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR p P.T•ER L7 - SEWER LINES -- ` DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL ' INTENDED USE OTHER WELL-._-^ PITS/SUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom — © Manteca Dia. of Well Excavation omestie/Private Travel peek L7 Trac Dia. of Weil Casing Ci Public y Type of Casing_ i Specifications f 1 Other n Delta Depth of Grout Seal 7 i i Irrigation —_ Approx. Depth l 1 Type of Grout Stern Surface Seal Installed by Repair Work Done ll Type of Pump H,P. - Wall Destruction U Well Diameter State Work Done Sealing Material (top 501) , Depth — Filler Material leelow 50'1 TYPE OF SEPTIC WORK; NEW INSTALLATION f 1 REPAIR/ADDITION I I DESTRUCTION I I INO septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial__r._ Other . Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK 0 Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT.O Method of Dlsposai Distanee to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line_ SEEPAGE PITS I I Depth Sipe _._ {Number SUMPS 0 Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS ❑ I hereby certify that I haveprepared 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 Diiltrict. Home owner or licensed agem'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 worif for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applinAcc, ired inspections. Complete'drewing on reverse side. �t Signed X Title:� Date: R DEPARTMENT USE ONLY ApplicatiDate � Area I Pit GrDate Final Inspection by Date_ Additional Comments: *70 yows A ❑ Stk 466-6781 O L 1 369.3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2M, Silk., CAA 95201 IFEE /A/MODUNT O E AMODU+NT(�REM1rrrED GASH RECEIVED BY DATE PERMIT NO. . EH 13.24 IREV.1/"5 J EH t4.2e ! J 1 ^ Y