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F ' rr _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Y PERMIT EXPIRES 1`YEAR FROM DATE ISSUED I (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 made in compliance with San'Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. l ill Job Address (_ Q City Lot Size PM Owner's Name � Address Phone _. Ili. Contractor t-� I � S ddress � � License No. Ph�`ne TYPE_OF_WELL/PUMP: !tel =NEW W�L_C'El _ - ., _WELLfREPLACEMENT ❑; DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SIEPTIC 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 D Manteca g :Dia.of Well( Dia. of We I Casin ❑ Domestic/Private O Gravel Pack - © Tracy Type of Casing Specifications i I l Public f_-1 Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation ,I_..Approx. Depth I I Eastern Surface Seal Installed by �p - Repair Work Done 0 Type of Pump + —__-M_p State Work Done_ �I Well Destruction ❑ Well Diameter Sealing Material {top 501 j �I Depth Filler Material (Below 50'1 �I I m TYPE OF SEPTIC WORK: NEW INSTALLATION fa; REPAIR/ADDITION l I DESTRUCTION l o septic system permitted,if public sewer is available within 200 feet.) t Installation will serve: Residence_' Commercial_ Other t Number of living units: �N Number of bedrooms -_ Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑: Type/Mfg Capacity No. Compartments 'gip PKG. TREATMENT PLT. ❑ - Method of Disposal �M r v , Distance to nearest: WeII�Fo`uh7l�tib7t Propeirty.Line IIiI _J LEACHING LINE 04 No. & Length of lines -" Total length/size- 0 ,l: FILTER BED Distance to nearest; Welli Foundation Property Line I` SEEPAGE PITS i I° Depth Size' " Number �M SUMPS Distance to nearest: Well/ Foundation Property Line DISPOSAL PONDS ❑. f �I I hereby certify that I have prepared this applicationxand�dhat the work will be done in accordance with San Joaquin'cbunty ordinances, state laws, and rules and regulations of the fSan Joaquin local Health District. 11 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 loy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature cern i he following: "I certify that in the performaAce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- r tion laws o alifornia." !� e applica s call for al requi d.iri cti.- mplate drawing on reverse si II Signe f Title: �h r1 -A / Date: _ p f FOR DEPARTMENT USE ONLY 08 f. Application Accepted by Date 7, Area Pit or Grout Inspection by i[ `- Date Final Innsspection by�� r .� Date a.,. G_ �( Additional Commento s': r- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 Tracy 835-6385 I Applicant- Returri.all- copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201, ' I FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO, INFO IM iM +.EH 13.24 Mcv.t/x 51 "` f,7 •U� �/ 1. I EH 14-28 - 'i