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_r yi L`. L APPLICATION FOR PERMIT ke . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA :+ O AJ17 d Telephone (209) 4Fi6-6781 , -� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) If r�0 t S . Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made!n 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. r i � of Size PM{�D O � city S� 'o Job Address pir, - ,q345 1 .�—a-Address �,o ` p Phone �� Owner's Name ' ri W�i t Address !'ZZ .- 11 s t License Phone No. Contractor 's �v' b TYPE OF WELLI.PI IMP: NEW WELL ❑ WELL,REPLACEMENT 71 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR .❑ OTHER ❑ 1 SEWER LINES DISPOSAL Fi D, PROP. LINE DISTANCE*TO NEAREST:vSEI TIC.,TANK-.,- - - t FOUNDATION AGRICULTURE WELL"�HER WELL `PITS/SUMPS INTENDED USE TYPE OF WELL T PROBLEM AREA (CONSTRUCTION SPECIFICATIONS 1-1Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation I Dia. of Well Casing 1h -• Specifications 11) Domestic/Private ;�7Gravel Pack ❑ Tracy Type of Casing r 1-1 Public 1-1 ;Other ❑ Delta Depth of Grout Seal Type of Grout _ I ! Irrigation _..Approx.yDepth I i Eastern -Surface Seal Installed by -� H p. State Work Done— Repair Work Done ❑ Type of Pump Sealing Material Ito 50'1 t Well Destruction ❑ Well Diameter �" - g p . j Depth`��- Filler Material (Below 50'1 a _. Qi TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR) l I DESTRUCTION No septic system permitted it publisewer is ;f available within 200 feet-i Installation will serve: Residence� Commercial_ Other r � �'� - 4i �, t< Cb Number of living units: Number of bedrooms � ' ate., + ► Water table depth ..r i Character of soil.to.a depth of 3 feet: I € SEPTIC TANK. ❑ Type/MfgCapacity No. Compartments 44-f ` - Method of Disposal PKG. TREATMENT PLT. ❑ q .� S.F 1 - i Distance to nearest: Well Foundation Property.Line LEACHING LINE om❑mNor& Leng h of lines tr""""'rTotal length/size FILTER BED D Distance to nearest: �-Well "� Foundation Property Line i I € SEEPAGE PITS I I Depth Number J Size '� � ,L# SUMPS Cl Distance to nearest..o Well ! Foundation Property Line f DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in ac cordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di$trict. % Home owner or licansed agent's signature certifies thefollowing: "I certify that in the performance of the work for which this permit is issued, I shall not ject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature employ any person in such manner as to become sub certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall employ persons subject to workman's compensa tion laws of California." "�+ Theapplicant um st cail for all u red+ins s. Complete drawing on reverse side'. t. .0, - Title: I Date: Signd X 2+► »,,,, -.�. - f FOR DEPARTMENT USE ONLY '�• ` Data I Area Application Accepted by a r Pit or Grout Inspection by Date Final Inspection by D7at�it, ,� Q "7 Additional Comments:,t► ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ T cy 835-6385 0. f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I - FEE AMOUNT DUE AMOUNT REMITTED UK a CASH RECEIVED BY DATE PERMIT�NO. - INFO r.EH 1124 1REV.1/H 51 � / r/ EH 14-26 "•��