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I APPLICATION`fOR PERMIT " t u SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he"eby 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 t/ (} �i City 71 Lot Size C e pM Owner's Name U e Address S 3 ?- 2 /7Qt/ Phone 11 n J /� Contractor s" h AddressA0 r( _ -j /��oZ �L-s:cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT DESTRUCTION 1: PUMP INSTALL_ ATION_ SYSTEM REPAIR ❑ OTHER F] { DISTANCE TO NEAREST: SEPTIC TANKc D. a"t SEWER LINES c�� -1- "' DISPOSAL F O.,01/f PROP. LINE a J � FOUNDATION ��z �AGRICULTURE�WELL' "j'OTHER WELL ,.PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i / [l ❑ Industrial Y ❑ Open Bottom Manteca Dia. of Well Excavation �1 Dia. of Well Casing t� ' Domestic/Private Gravel Pack ❑ Trac 'Type of Casing / f Y YP 9 Specifications [� M Public ❑ Other ❑ Delta i Depth of Grout Seal .�� z Type of Groui t'`�7 CC/rI !tI I i Irrigation ��0 .-Approx. Depth { I Eastern Surface Seal Installed by Repair Work Done ❑ - Type of Pump H,P. State Work Done r. r ,Is Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ' t ( Depth Filler Material (Below 50 � I TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADDITION 1,1 DESTRUCTION I 1 {No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg* Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line i �I LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I DepthNumber Size 'I ' SUMPS hl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t I hereby certify that I have prepared this_application.and that the work will be done inaccordancewith 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: "I certify that in the performance of the work for which this Permit is issued,'l"shall not 1 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 folio : "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 rfor a." ^ ` The applica m call fo all re di s tions. Comple a drawing on reverse side. ' E Signed Title: D ate: _ t ( FOR DEPARTMENT USE ONLY Application Accepted by i l Date $ LN V8 Area G Pit Grou Inspection by Date Final Inspection by Date ; Additional Comments: �t....-4.yX ,, ae ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy � — 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED RECEIVED BY DATE PERMIT NO. + EH 13-24'I HEY.r/x 51 / EH 14.26 Id, C� �A -- 0- �I,