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APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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 made in compliance with San Joaquin County Ordinance No,549 for sewage a a or it t 1 on for welt! um Local Health District. 9 application is P p and the Rules and Regulations of the San Joaquin Job Address 2— o yl5 .y-- City 6�O Lot Size Owner's Name r r` 'f ` pPM ��yy- " p Address t1 8 - 1 ��d Phon Z Contractor ,Yr � t �•4S�`t% '55 1716 NEW WELL TYPE OF WELL/PUMP: License No.C*'�Af F` 6 ��- WELL A PLACEMENT�'..� �-`—""-"s' hone - PUMP INSTALLATION [I WELL r DISTANCE_ _TO_NEAREST: SEPTIC TANK SYSTEM REPAIR Ll-- �� OTHER ElSEWER LINES FOUNDATION DISPOSAL FLD. PROP, LINE INTENDED USE ~_ AGRICULTURE WELL OTHER WELL TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS L7 Industrial PROBLEM Bottom —� F1 Domestic/Private ❑ Manteca Dia. of Well Excavation -2— r'! Z J� D Grave! Pack El Tracy '7-1, Dia. of Well Casing f' Public ❑ Other Type of Casing G- G, fl Delta Depth of Grout Seal ; Specifications , 1 I I Irrigation c�,,� 6 r $ Type of Grout�� {pe of pum Depth E I Eastern Surface Seal Installed by Repair Work Dane L7 Type of Pump � H.P. T--- ell Destruction ❑ Well Diameter state Wor Done _ -- M 0 h i t0/i j Depth Sealing Material (top 50•) TYPE OF SEPTIC Filler Material (Below 50') WORK; NEW INSTALLATfON 1 1 REPAIR./ADDITION I 1 OESTRUCTIpN I I INo septic system permitted if public sewer is Installation will serve: ResidenceCommercial_ Other available within 200 feet.) Number of I ing units: Number of bedrooms Character of s0114Q a depth of 3 feet: SEPTIC TANK Type/Mfg Water table depth PKG. TREATMENT PLT, Cl Capacity . No. Compartments Distance to WellMethod of Disposal Foundation Property Line LEACHING LINE ❑ & Length of lines FILTER BED Distance to nearest: WellTotal length/size Foundatr Property Line SEEPAGE PI I 1 Depth SUMPS Size — Numhar Ll Distance to nearest: Well Foundation DISPOSAL PONDS [] Property Line 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 Di§tnct. 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, f 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 must II required inspections. Complete drawing on reverse side. Signed X [/ Title: Date: µ FO DEPA TMENT U5E ONLY Application Accepted by t I Date G+� Area Pit or Grout Inspection by Data___,�_ Final Inspection by Additional Comments: Date ❑ Stk 466-6781 0 Lodi 369-3621 1] Manteca 823 7104 ❑ Tracy 835 6385 FEE AM Applicant - Return all copies to: Environmental OUNT DUE Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT REMITTED CK RECEIVED BY CASH DATEEH 14-28 PERMIT N0, + EH 18-2 (REV.tiHSl c r 0 Pi. O �/�