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` v IIs J. +^�.ti.' _. • 5 - ... APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTINCT t 1609 E. HAZi' AVE.; STOCKTON, CA Telephone'(209) 466-6781 f , PERMIT EXPIRES 9 YEAR FROM DATE ISSUED N (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her'' I made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations Local Health District. ern described, This application is g ns of the San Joaquin Job Address City SN Lot Size ' �. PM Owner's Name A .� �' -' —ddress — Contractor�� ainP Phone Address TYPE OF WELL/PUMP; NEW WELL ❑ License No. Phone p� ! PUMP INSTALLATION ❑ WELL REPLACEMENT DESTRUCTION ❑ DISTANCE TO NEAREST. SEPTIC TANKSYSTEM REPAIR, OTHER ED—�� SEWER LINES _yam! DISPOSAL FLD. FOUNDATION AGRICULTURE WELL PROP. LINE INTENDED USE OTHER WELL PITS/SUMP$ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom —� ❑ Domestic/Private ❑ Manteca Dia. of Well Excavation- \ ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing n Public ❑ Other - ype of Casing `! ❑ Delta Depth of Grout Sea! Specifications ❑ Irrigation Type of Grout —�RP►ok. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump `u/�►— Well Destruction ❑ —�~ H P' "� ,'r State Work Done A71—:116 C At A, WeII Diameter Sealing Material (to 50'1 R Depth Filler Material (Below 50'} LAC TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIA/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public se Installation will serve: 'Residence Wer is Commercial� available within 200 feet.) � [ Number of living units: Other l 1 Number of bedrooms Character of soil to a depth of 3 feet-- SEPTIC eet:SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT.❑ T Capacity—. No. Compartments Distance to nearest: WellMethod of Disposal Foundation Property Line. (L� LEACHING LINE4 1 ❑ N.:-.& Length of lines FILTER BED ❑. Distance to nearest:: # Total length/size Well Foundation Property Line. SEEPAGE PITS ❑ Depth SUMPS Size Number 4 ❑ -Distance to nearest: well DISPOSAL PONDS ❑ Foundation�� Property Line. I hereby certify that I have.prepared this application and that the work will be done in accordance with San Joaquin county ordinance rules and regulations of the San'Joaquin Local Health District.. Home owner or licensed agent's signature certifies the following: s, state laws, and employ an g: "I certify that in the performance of the work for which this permit is issued, I shall not P Y e person in such manner as to become subject to wor�Cman's compo Sat&laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work far which this permit is issued,l shall employ tion laws of California." The applicant must call for all re" ins etions Complete drawing on reverse side, p y peons subject to workman's compensa_ Signed T Title: _ .� 1�//I/r.0 LdcG Date: FOR DEPARTMENT USE ONLY f r Application Accepted by' - �- • Pit or GroDate Grout Inspection by � �• - - Area Date `' - Final Inspection by Additional Comments: Date ❑ Stk 466-6781 1. ❑ Lodi 369-3627 ID Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all capias to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O.'Box 2009, Stk., CA 95201 FEEAMOUNT DUE INFO AMOUNTREMITTED,irr.. CK / CASH RECEIVED 6Y DATE + EM 13-24(REV.r.in57 [+� PERMIT'NO. EH 14-28