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r APPLICATION FOR PERMIT SAN JOAQUIN kOCAL HEALTH DISTRICT 1601 E..HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) 1 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 o.549 for sewage or No. 1862 for well/pump and the Rules a Local Health District. nd Regulations of the San Joaquin is Job Address ' City wLot Size ,r /� /� �7 / b PM `Address` s . 6o 7 G_/�T}}'� Phone Contractor t Address License No. Phone TYPE OF WELL/PUMP: NEWN WELL,,❑ t' WELL REPLACEMENT ❑' _" s c, DESTRLfCTlO PUMP INSTALLATION`❑ SYSTEM REPAIR'❑ DISTANCE TO NEAREST: SEPTIC TANK OTHE ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION { AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL-�', PROBLEM`AREA CQNSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom a"Manteca- CONVlaS(Well Excavation ❑ Domestic/Private Q Gravel Pack ' Dia. of Well Casing F ❑ Tracy Type of Casing ¢ C ❑ Public ❑ Other • ❑ Delta Specifications +, - Depth of Grout Seal Type of Grout ❑ Irrigation �Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump IH p --n ,f a -` State Work Done Well Destruction ❑ Well Diameter Sealing Material {top Depth i " "Filler.N}aterial`(Be"low'50'1 i • TYPE OF SEPTIC WORK: NEW INSTALLATION.❑;- REP AIR/AODITIO T1:111, CT11)N Dr+ t� (No Septic s stem permitted if public sewer is " Installation will serve: Residence Other . Commercial= ! available within 200 feet.) 3 - Number of living units: f:i%t'Numb&of bedrooms 'it t -� t i� -� Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity INC PKG. TREATMENT PLT. ❑ No. o Method of Disposal Distance to"nearest: Well Foundation i Property Line �. LEACHING LINE s w ❑ Na. & Length of lines f Total length/size FILTER BED ❑ Distance toFnearest: Well " 1 Foundation Property Line i' SEEPAGE PITS ❑ Depth I Size } Number i SUMPS ❑ Distance:io.nearest: Well f 3 - Foundation E Property Line S DISPOSAL PONDS Ll . : # t } hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, "state laws,iand-'" rules and regulations of the San Joaquin Local Health District: i Y Home owner or licensed agent's signature certifies the following. t 's . r g: "I certify that in'the�pertormance 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 work far which this permit is issued,I shall employ tion laws of California." P Y persons subject to workman's compensa- The applicant must call for all re ed nspections. Complete drawing on reverse side. /' ,. Signed 1 Title: Dater , ti"Ye,�-� OR DEPARTMENT USE ONLY Application Accepted b .g .ft i �� Pit or w_, _ _ Date Area__ Grout Inspection y ^Date p } Final Inspection by Date_ Additional Comments:ED stle, ✓ ,466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6395I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:,,P.O. Box 2009, Stk., CA 95201 FEE r» I C«. INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY Gr DATE PERMIT'NO. r +-EH 13-241pEV..t/e51 �►—/" , EH 1428