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p Weil --a// .2 � r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1°YEAR FROM DATE ISSUED-' '''` (Complete in Triplicate)' `l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or Vinstall 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 (��•%Il7�� F''' City �'Lot Size PM 14 11 Owner's Name /�^, 1 Off ddress `s/,/` �-'�`�' `� �u Phone y/zg, Contracto��rlT� 1� r Address �� S>L7? License No. Phon TYPE OF WELL/PUMP: NEW WELL ❑; WELL REPLACEMENT ❑ DESTRUCTION ❑ --�3 PUMP.INSTALLATION SYSTEM REPAIR ❑ OTHERS 3- d DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6_46 DISPOSAL FLD�a PROP. LINE FOUNDATIONTURE WELL- OTHER WELL_,t5110__ PITS/SUMPS Z4ffC) INTENDED USE- — TYPE OF WELL-- /70BLEM AREA- CONSTRUCTION SPECIFICATIONS - - J,/1 1:1 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation 6 Dia. of Well Casing 7" ❑ Domestic/Private XGravel Pack. ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ,4 - ❑ Delta '> Depth of Grout Seal Tf rout { ❑ Irrigation _Approx. Depth ❑�E�as7es Surface Seal Installed b .Pr Repair Work Done ElType of Pump 77``11CCiH.P. State Work'Done lJ�� �iWell Deessjfuction ❑ Well Diameter Sealing Material {top 50') I�•ti jrlr�f'/� Depth f g Filler Material (Below 501, A64W, CIFEc 0 ' TYPE OF SEPTt WORK: NEW INSTALLATION ❑. REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence_ Commercial_ Other I Number of living units: 'Number of bedrooms ` Character of so'il.to.a depth of 3 feet: 4Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑- n Method of Disposal Distance to nearest: Well Foundation Property Line i. I LEACHING LINE ❑ No. & Length of lines Total length/size } FILTER BED i ❑ Distance to nearest: Well Foundation Property,Line j I � T SEEPAGE PITS ❑ Depth Size °+ y Number SUMPS ❑ Distance to nearest: Well - Foundation Property Line I f 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. 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 nota 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, I shall employ persons subject to workman's compensa tion laws of California." =' The applicant must call for all r uired'iins�pecAtio`ns. Complete drawing on reverse side. Q' _ Signed X �� Title: Date: ��— T FOR DEPARTMENT USE ONLY . Application Accepted by - " ''Date Area 17 Pit or Grout Inspection.by Date lZFinal Inspection b Date C-E-12-may Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 - FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO C + EH13241REV.t/a57 * 4 C_ EH 1426 2"r, l