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A�Y. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 l 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 v 6 Ill Cit of Size Z I PM r "l I I� Owner's Namegr �.!P.�� _ Address Phone �I/'r/` Contractor/��1� �!/(/ ✓ Address 69/z V / License No. Phone Io, TYPE OF WELL/PUMP: NEW WELL w WELL REPLACEMENT ❑ DESTRUCTION ❑ I` PUMP INSTALLATION E `r, f SYSTEM REP iR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES fDo DISPOSAL FLD. PROP. LINE I� y FOUNDATION ° AGRICULTURE WELL OTHER WELL PITS/SUMPS" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /' ! ustrial L1 Open Bottom '171 Manteca-.' Dia- of Well Excavati Dia. of Well Casing mestic/Private ] Gravel Pack Q Tracy Type of Casing G Specifications irblic I i Other ❑ Delta Depth of Grout Seal J00 tTyp Grout Jr r AVA Kl rigation Appm . Depth yI 1 Eastern Surface Seal Installed by air Work Done ❑ Type of Pump-.SNLLt H,P. _ � � State Work Done Well Destruction ❑ Well Diameter � Sealing Material (top 50') Depth - " Filler Material IBelow 50'1 I� TYPE OF SEPTIC WORK: NEW INSTALLATION I i .REPAIR/ADDITION I I ,DESTRUCTION l I INo septic system permitted it public sewer is available within 200 feet.) I. Installation will serve: Residence J14 Commercial= -Other--- i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I� I PKG. TREATMENT PLT. ❑ Method of Disposal IM �,.• Distance to nearest:, Well Foundation Property Line j LEACHING LINE ❑ No. & Length of lines - Total length/size �M FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS.: i I Depth �`. Size - Number IM SUMPS Ll Distance to nearest: j Well Foundation Property Line �' 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 Diltrict. 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 not employ any person in such manner as to become subject to workman's compensation taws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance ofthework for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applic nt mus&for allr quired in ti Complete Complete drawing on reverse e. Signe X itle: i� :L /G'+� Date:— I OR`PARTM NT USE ONLY I� i At— Application Accepted by iAA eZ b 1 Date SR ` Area I� Pit or Grout Inspection y Date + �/ Final Inspection by_; W� �? N Date V, Z Ck Additional Comments: z �� LJ Stk 466.6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835`6385 w Applicant Return all copies to:-Enviionmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk., CA 95201 ., t. 6 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT�NO. NFO - _. - CASH "i _ _.._ -�- r a.EH 13-24 rREV.1/1151 �� 9 r 4�1111 EH 14-2$ 1