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--J APPLICATION FOR PERMIT sy SAN JOAQUIN LOCAL HEALTH DISTRICT J, 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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 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 f City _�!� !� Lot Size . PIM—. aw. 7 Owner's Name Address _. Phone _. dr Contractor Address _ JG _ icense No.� Phone TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT U DESTRUCTION J PUMP INSTALLATION ❑ ,SYSTEM-REPAIR F,, OTHER ❑ _ DISTANCE T.0 NEAREST: SEPTIC TANK _ SEWER LINES �` DISPOSAL FLD. PROP. LINE FOUNDATION — AGRICULTURE WELL 0TH L PITS/SUMPS 'I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC P�C)FJCATIONS L' industrial Open Bottom f, Manteca We11 Excavation— _ Dia. of Well Casing ❑ Domestic/Private Gravel Pack D Trac Type of Casing_ . Specifications ❑ Public G Other Ita r Depth of Grout Seal Type of Grout ❑ Irrigation _Appy epth U Eastern , Surface Seal Installed by Repair Work Done C of Pump 1 H.P.` ...State Work Done— ! Well Destructic _I Well Diameter _ Sealing Material (top 50') Depth �'. Filler Material (below 50'1 —- TYPE OF SEPTIC WORK: NEW INSTALLATION. _ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is z available within 200 feet.) Installation will serye: Re dente —L Commercial_ Other Number of living units: Number f rooms-3 r Character of soil to a depth of 3 feet: Water table depth - _ - SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _- PKG.TREATMENT PLT. ice} Method of Disposal Distance to nearest: Well�!l - Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ - - Total length/size FILTER BED ❑_,Distance to nearest: Well Foundation — Property Line �. I SEEPAG PITS ❑ Depth Number S UMP LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS U 16��7 vLG�I'"T �^ s`$"� cj� 2J 1 `! 'Y 2 1,1r I hereby certify that I have prepared this applicatiori and that the work will be done in accordance with Sart 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 cattify 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."Contractof s hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ-persons subject to workman's compensa- tion laws of California." The applicant n1usl ca for squired ' spections. Comp�le drawing on reverse side. 9 1 j Si ned �i` �� '�C�'—Title: `�' �Gj'7-��c_. Date: r ! FOR PARTMENT USE ONLY 1 Application Accept y {�7 _ Date �7 Area Pit or Grout Inspec y ate Final Inspection by Date L—IL—D Additional Comments: 72 ❑ Stk 4664781 ❑ Lod f 369`3621 ❑ Manteca 823-7104 ❑ Tracy 635.8385 Applicant -Return all copies to: Environmental Health Parmit/Services 1601 E. Hazalton Ave., P.O_ Box 2009, Stk., CA 95201 FEE AMOUNT DUET AMOUNT REMITTED GASH RECEIVED BY DATE I PERMIT NO.. `\ INFO 1 ♦ EH 13-24(REV.1'+t 5; EH 1426