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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t } 1601 E. HAZELTON AVE_, STOCKTON, CA ` .;' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) F 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. ti i . Jab Address �� 0-rdlna Sr City Lot Size PM 93/— 33 D r� Owner's Name Address e �f GontractarJ Address License No. Phone_ T PE OF,WELL/PUMP: �� It NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION `'; ` PUMP INSTALLATION �� SYSTEM REPAIR LJOTHER ❑ ll# # f .DISTANCE TONE*Af#ES TANK SEWER LINES DISPOSAL FLD. PROP. LINE• o �( r� FOUNDATION AGRICULTURE WELL OTHER WELL P{TS/SU`VIPS \ l ,�\ INTENDED USE TYPE OF WELL PROBLEM ARE STRUCTION SPECIFICATIONS s \` ! 1 W J D Industrial ❑ Open Bottom ❑ Manteca Dia- of a ation Dia. of Well Casing �omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ^ Specifications M .�- r- ,ih H, a. f"1 Public'' ❑ Other w,..,n Qelta' —Depth of Grout Seal' "` Type of Grout=_ . 1 1 Irrigation A-Approx. Depth l l Eastern Surface Seal installed by I - Repair Work Done ❑ Type of Pump H.P. State Work Done P I N Well Destruction ❑ Well Diameter Sealing Material Itop 501 I Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION I (No septic system permitted if public sewer is' —available within 200 feet-) ; Installation will serve: Residence-A Commercial Other Number of living units; ,, _. Number:of bedrooms f Character of soil to a dtepttii of 3 feet: SEPTIC TANK i Water table depth j I17�,iTYpe/Mfg """"""� 'd% �'" C ! ' Capacity � No. Compartments k PKG. TREATMENT PLT. ❑ ��4i [ M Method of Disposal j ' -..v. Distance to nearest: Well iFoundation Property Line •E EACHWG LINE ❑ I No. & Length of lines d Total length/size l T FILTER BED ❑ I Distance to nearest: Well Fouhdatioil Property Line t I � i SEEPAGE PITS I 1Depth Size Number SUMPS L] I Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 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. l I 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 t� 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: '9 certify that in the performance of the work for which this permit is issued,t shall employ-persons subject to YFcrkman's compensa- tion laws of California." 1t 1 The applicant must call for at required inspe tions. Complete drawing on reverse side. I �E Signed X Title: Date: I, FOR DEPARTMENT USE ONLY Application Accepted by Date Area ]� Pit or Grout Inspection by II Date Final Inspection by 1 Date +z Additional Comments: _29-92A ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 E] Tracy 835-6385 Applicant- Return all copies' o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +,EH 13-24(REV.t/H 5) / F 07J 2_1Z d , A EH 14-25 v