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�- AK APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete'in Triplicafe) - ` -' "� t�,." + ,� 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 R41es and Regulations of the San Joaquin Local Health District. Job Address Lot Size PM �r -Owner's Name �e Address 3M C6__W_'7b7L -Phone Contractor r/ f Address License No. Phone 'TYPE OF WELL/PUMP: ,II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP'IIIINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' „;.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE. Sr - FOl'11VDi4TI0N'""'""�"�"`"""` ;4GRICULTURE WELL' = OTHERw1IJECC— "rpITS'/SIJh/!PS �.. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal" Type of Grout-----:- 0 Irrigation1i ------Approx. rou#❑ Irrigation ------Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEWINSTALLATION ❑ REPAIR/ADDfTION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V t + available within 200 feet.) Installation will serve: Residen,e_ Commercial— Other ` Number of living units: .JMNumber of bedrooms " Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.'TREATMENT PLT. ❑ � s.. •- --�= =n �.. =x-<- - - -. —. -" Method of��Disposal Distance to nearest: Well Foundation IProperty Line I a. � LEACHING LINE E-1 No-'i& Length of lines — �-` Total length/size i FILTER BED C] Distaince to nearest: I Well Foundation Property Line * ; SEEPAGE PITS L2 Depth Sfiza Number ° SUMPS ❑ ,Distaince. to:neare6t:f -tl Well Foundation Property Line DISPOSAL PONDS ❑ I;I 1. _ A 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:,:,l-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, I shall employ persons subject to workman's compensa- tion laws of California." $i r , ;- I The applicant u t calf.or I requir inspection Complete drawing on rev a side. Signe zTitle: ' ., Date: -^ FOR DEPARTMENT USE ONLY Application Accepted by dI Date.V� r®/��_ rea Pit or Grout Inspection'by Date Final Inspection by y F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Entironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY , DATE PERMIT'N0. +EH3-24(REV,)/B 5) 19Ss �a L ��' �/Q ds� /� !p EH 11426