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r APPLICATION FOR PERMIT w fB4 SAN JOAQUIN LOCAL'HEALTH DISTRICT a 1601 E.�WAZEI`TON AVE„ STOCKTON CA Telephone-(209)-466-67$1 PERMIT EXPIRES VYEAR FROM'DATE ISSUED' {Complete in.Triplicate f 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 forzwell/pump and the Rules and Regulations of the San Joaquin Local Health District. 'W F" aJ . Y -x 1. t• « ��qqg �.d , CJ , ln' {` 4y` Cityu N . LotSize PM , - Job Address r 3 r Address ""6 J uj 0 Liu&b . , Phone �3 � Owner's Name �}�cul Contractor'�4" rn& i� Address Q t d . License No.�Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE CEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' p Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -.�Approx. Depth El Eastern JJ/ Sdrface Seal Installed by Repair;Work Done ED Type of Pump H.P. Q? t State Work Done df— AF Well Destruction ❑ 'Well Diameter 3 'r/ —Sealing,Material-(top,50') E "Dept�— Filler Material (Below 50'1 f ^TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is f available within 200 feet.) X41 stallation will serve: Residence_"'�Comniercial_ Other f f Number-ofliving units: Numb/,o bedrooms 1 r Character of.soil to a depth of 3 f:-� Water table depth f SEPTIC TANK ❑ Type/Mfg �37� r f Capacity Na. Compartments } t PKG. TREATMENT PLT. ❑ ` r S-A1' +� f .x Method of Disposal F y Distance to nearest: Well? Foundatio ? Property Line . LEACHING-LINE�, / O No. & Length of lines Total length/size 1 ' FILTER BED ❑ Distance-to"nearest: Well Foundation Property-Line ! ` SEEPAGE P1TS ❑:i.fJep'th--� '-}"�""" Site t Number -'-- SUMPS ! `❑� Distance to nearest: Well Foundation _ _Property Line i DISPOSAUPONDS ,1 ❑ t F 'j hereby,certify'that l 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: "I certify that in the performa celof the work for which this permit is-issued, I shall not employ any,person in such manner as to become subject to workman's 6brApensation laws`of California'"Contractors hiring or sub contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I'shai lle.ploy persons subject to workman's compensa- tion laws of California." # : ' r The applicant m t c quired inspections. Complete drawing-o verse side. F• Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by' Date Area ! Pit or Grout Inspection by Date Final Inspection by." Date `Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.95201' FEE AMOUNT DUE AMOUNT REMITTED GK# J RECEIVE' BY DATE PERMIT'NO. I INFO � I I + EH 113-24(REV.1 EH 1426 4