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4 -- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y (Complete in Triplicate) ! Application is hereby madI t the San Joaquin Local Health District for a permit to construct and/or instal!the work herein described. This a lica i j 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. �0 AVZ, ']T S'09"j T-OAW RC1 IPtY� ~� j o --v/. Job Address 3Dn� �j///' r�?C�l_��'`� Cit 7T Y Lot Size PM l Owner's Name C!f/ - D Address Phone Cbntractor Address Z/z_ License,No—. �_�P_hone�_ . TYPE OF WELL/PUMP: NEW WELL ❑ cWELL REPLACEMENT LI DE DESTRUCTION,k ' PUMP INSTALLATION Q��` J , �` '`` b �> S SYSTEM �EPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. _DISP_pSAL-FLD.- . pROP. LINE FOUNDATION /,AGRICULTURE WELL OTHER WELL PITS/SUMPS / Li[INTENDED USE T-YP.E,OF--WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial r 111 ❑ Open Bottom w[] Manteca Dia. of Well Excavation Dia. of Well Casing 4 QDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑Public ❑ Ot7er ❑ Delta Depth of Grout Seal ❑flrri ation g Type of Grout �! l gi Approx. Depth ❑ Eastern Surface Sea! Installed by ` Repair Work Done ❑ Type of Pump H.P. State Work Done Z. Well Destruction W� Well Diameter � Sealing Material (top$0') i1 Depth Filler Material (Below 501 TYPE OF SEPTICWORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Q jNo septic system permitted if public sewer is 4favailable within 200 feet.) Installation will serve: Residence— Commercial, Other Number of living units: Number of bedrooms w.- Character of soil to a depth of 3 feet: Water table depth SEPTIC TA7VK Q Type/Mfg Capacity No. Compartments . PK!G. TREATMENT PLT. F! Distance to nearest: Well Method of Disposal l Foundation Property Line ! ' c = LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line cSEEPAGE PITS ❑ Depth i—Size Number r.SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS F] 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: ! m to an '9 certify that in the performance of the work for which this permit is issued I shall not e p y y 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 tion laws of California." �r P Y persons stubject to workman's compensa- tion applican st c 1!f all r ired inspections. e pections. Complete drawing on re ide. Signed Y i Title: , rr1 D ite;,.. FOR DEPARTMENT USE ONLY "'�';? AppGcatian.Accepted by � tilt := r+y i. 1 Date 2 r ` .- ,;rea `l Pit or Grout Inspection by Date i 1? oz � ` Final Inspection y ate rn j �� ,.,U � - - , Additional�Gomments: It '< , ❑ Stk 466-6781 1 ❑ Lodi 369- .1^ n _Man.i6a__2M_ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA'9.01 AA') FEE AMOUNT REMITTED ; INFO AMOUNT DUE CK CASH RECEIVED BY DATE IT'NO. t EH 13-24�(REV. EH 74-28