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r APPLICATION FOR PERMIT SAN JOAQUIN''LOCAL HEALTH DISTRICT aur 1601 E. E. HAZT ON AVE. STOCKTON CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROrVIENTAL HEALTH! Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h2rnRde� r b �511'h�', licarion 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 5 City Lot Size PM r t1 Owner's Nam �-tt FL - Address Phone Contractor Address P0 / License No. 3 Z Phon c � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "'�FOUNDATION ""' AGRICULTURE-WELL— — 'OTHER-WELL:,-t�TPITS/SUMPS� - �- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Neeomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public C1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by } Repair Work Done ❑ Type of Pump v H,P. Z State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION i:I -REPAIR/ADDITION l 1 DESTRUCTION I1 (No septic system permitted if public sewer is available within 200 feet.) r , Installation will serve: Residence_ Commercial_ Other I 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 t PKG. TREATMENT PLT. ❑ Method of Disposal.. Distance to nearest: Well Foundation Property Line J LEACHING LINE ❑ No. & Length of lines Total length/size' 1 FILTER BED t ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS 5 LI Distance to nearest: Well Foundation Property Line _a Y-....� DISPOSAL PONDS't.- �© _-� — ,�� , .-..-�....,-��..,�_..- :.-,...r. =---•.ems . ��,. ...�.R v 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"He�lthJDistFic`t. - 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 performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." 1 t The applicant, u i all far-all required inspections. Complete drawing onr arse side. Signed X ��[ .rte ��=-�^�" Title: - ." '. _ Date: �.� t FOR D ARTMENT USE ONLY Application Accepted by Date Area 42 Pit or Grout Inspection by Date - Final-Inspection by Dat;_-?- I Additional Comments: '• ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ! ♦ EH t3-24(REV.t/lis) EH�14-2e