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MENNEN APPLICATION FOR PERMIT `ew C 6-a3-g 7 ,. SAN JOAQUIN LOCAL HEALTH DISTRICT D 1601 E. HAZE T ON AVE., STOCKTON, CA ;3 Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l 1 3 (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 �C✓i Lot�Size ,/ to' s t PM s� Owner's Name _ Address ,c/ �7 "L!4 ) Phone Contractor I0 Address License No. Phone TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 [3,Industrial El Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ DOmesUc/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications T of Grout ElPubGc-___. Other •O'Delta Depth of Grout Seal Type Irrigation' _�lpprox. Depth ❑.Eastern Surface Seal Installed by %iepair V�(� bone Type of Pump H.P. State Work Done + Well uction ❑ Well Diameter Staling Material (top 501 . Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION E�PAI/R/ADDITION ❑ DESTRUCTION F1 (No septic system feet.) 1f public sewer is _ Installation will serve: Residence_ Commercial� Other Number of living units:-- Number of bedrooms l� i Character of soil to a dep h of 3 feet: -Water table depth 1 SEPTIC TANK 1-- Type/Mfg Capacity-1-0,44-- No. Compartments �. PKG. TREATMENT PLT. ElMethod of Disposal Distance to nearest: Well 1 Foundation�l, Property Line_57 v LEACHING LINE ®/No. & Length of lines l� Total length/size s FILTER BED ❑ Distance to nearest: Well _ Foundation�-�-- Property Line !n SEEPAGE PITS YY Depth Size____ __ Number SUMPS ❑ Distance to nearest: Well s' Foundation /�-- Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that 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 rn 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 Caled,I shall Contractor's hiring c subcontracting 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 m for requir inspections. Complete drawing on reve a side. Signed Title:7 Date: 9 0 F DEPARTMENT USE ONLY Date -� Area Application Accepted by it r Grout Inspection by Date 6- 7Final Inspection by P Dat�v � Additional Comments Ll Stk 466-6781' 'Lodi 369 3621 ❑ Manteca 823-710k- El Tracy 835 6385 Applicant- Return all copes to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK S FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO T� EH 13-24(REV.i/65) U`D O EH W28