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; �r APPLICATION-FOR PERMIT 5 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION AVE., STOCKTON, CA Telephone {209) 466-67131' . r. c. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate}M Application is hereby made to the Sah 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.Rulas and Regulations of the San Joaquin Local Health District–,,,._., Job Address u City Lot Size _ PM , _ , q � � � _::�.��",{ /� d a, �' /L Phone 3 fie' 7 0 Owner's Name ��ce� Rddress ► Contractor's Name License No. ' 3 73 Phone .TYPE OF WELL/PUMP: NEW WELL '❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ' AGRICULTURE WELL _ OTHER WELL PITS/SUMPS — INTENDED USE',,,_TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom :.{ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack---_, --E Tracy Type of Casing Specifications ❑ Public ElOther ❑-Delta Depth of Grout Seal Type of Grout a frrigation + _--Approx. Depth ❑ Eastern- _ Surface Seal Installed by Repair Work Done " Type of Pump 'r, � H.P. State Work Done/,-" ° 0 � Q ' Well:Destruction ❑ Well Diameter Sealing Material (top 50') Depth z- Filler Material (Below 501 PA TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION(❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ryry�� } available within 200 feet.) "N Installation will serve: Residence__ Commercial ._ Other 00 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg _.Capacity No. Compartments PKG' TREATMENT PLT. ❑ Method of Disposal ^ Distance to nearest: Well Foundation Property Line LEACHING LINE {' ❑ `No. & Length of lines Total length/size / FILTER BED' y ❑ 'Distance to nearest: Well F6undatloh Property Line SEEPAGE PITS ❑ Depth } Size, .r Number r SUMPS . 4—-O-1Distance to-nearest:.. -- Well,— 42- Foundation 7L Property Line 6 :DISPOSAL PONDS] I hereby certify that I have prepared thii•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'i)istricf ,-;�-__ 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."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performanc6-bf the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicanttt�all for al r�ired nspections. Complete drawing on reverse side. Signed X ilry ue: 2&A74 Date: 4e_ FOR DEPARTMENT USE ONLY �� . Application Acce ted by Date Area fit' M - - Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: k — ❑ Stk 466-6781 = ❑ Lodi 369-36211 4- EIManteca -823-7104 ❑ Tracy 835-6385 } Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 It FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH +EH 1324(REV.10163) `" f