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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) E� Application Is hereby made to the San Joaquin Local Health District for a permit to'construct and/or install the work herein described. TMs 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 Sen Joaquin Local Health District. ,lob Address City q±XWJc t D — Lot.Siza4 f1 r x l Ft p PM Owners Name Snuthland Carp. Addresb 2 711 Contractors Name - License No. Phone TYPE OF WELL/PUMP: NEW WELL lX WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAMC SO SEWER LINES DISPOSAL FLD. ? PROP. LINE loft 3OO�a•PkTSlSUMPS FOUNDATION �� AGRICULTURE WELL ��tDTHER WELL (\ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2 in. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �{7 PVC Specifications Domestic/Private )p Gravel Pack ❑ Tracy Type of Casing •0 2 0 in. 4 i0ft.min Cement ❑ Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 4 of prox. Depth ❑ Eastern Surface Seal Installed by Sierra Pacific Drilling � Repair Work Done ❑ Type of Pump H.Pr State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system m permittfeet ted d public sewer is avaInstallation 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 E) Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines .. 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 ❑ 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."Contractors 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 must call for all required inspections. C plate drawing on reverse side. i= �✓ Title: Date: Signed I P ENT USE ONLY Application Acd b Data S p` Pit or Grout in;;. b Date final Inspection by Date-Ll�--Y� Additional Comments. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9=1 FEEAMOUNT DUE .. AMOUNT REMITTED CASH .i RECEIVED BY DATE PERMIT N101. INFO <J . EH tsar IREV.+01871 EH+�