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r APPLICATION FOR PERMIT #-- t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA No Telephone (209) 466-6781, " Val PERMIT EXPIRES TYEAR FROM DATE ISSUED _ " (Complete in Triplicate) 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. Jab Address City :St Lot Size PM Owner's Name Tf l 1 r VV F• b)0 Address �_. Phone Contractor L t` L~.a Address Or License No. Phone �_.."__ TYPE OF WELL/PUMP: NEW WELL O % WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .rj FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy I;. Type of Casing Specifications M Public Other C-1 Delta Depth of Grout Seal Type of Grout I I Irrigation '_-Approx. Depth I i Eastern Surface Seal Installed by _ 4 Repair Work Done L7 Type of Pump H.P. State Work Done _ 4 Well Destruction 17 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I eptic system permitted if public sewer is Q available within 200 feet.) Installai on will serve: Residence L___C1mrnercial Other Number of livin 9 units: _ Number of-bedrooms' �— Character of soil to a depth of 3 feet: k Water table depth SEPTIC TANK ❑ Type/Mfg *'�� _'Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I i 3 Distance Ao nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines '" Total length/size FILTER BED ❑ Distance to nearest: Well: Foundation r Property Line r SEEPAGE PITS i'I Depth`-' Size" ! Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS LI L ij 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:::) 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 ce s 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 law Californ" i e applica t t II fo all quir ins Complete drawing,9n reverse A I � ` Signe Title. Date: Y F I]EPARTMENT USE ONLY T Application Accepted by �A�A�V1A _ Date_ Area. I Pit or Grout Inspection by Date Final spection by Date Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 CI Manteca 823-7104 --0STracY 835-6385 _.Applicant_,Return all copies.to:-Environmental-Health Permit/- ervices 1601,. Hazelton Ave.,.P.O._Box.2009,-Stk.,-CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. � + EH 13-24IREV.t/nb) ' EH 14-28 2,