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- r APPLICATION FOR,PERMIT SAN JOAQUIN ,LOCAL,HEALTH DISTRICT 1601 E. HAZEL TON,AVE., STOCKTON, CA Telephone (209) 466 6781' PERMIT EXPIRES': YEAR,FROM,DATE ISSUED, ,1, till Oni,V),1:,'3„,(Complete 4n Triplicate)x2,iYi r.e -,icq$,-.0i 0 1.:, 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 compiiance: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. . ' i�� vXkr'iP: :ftlla t F C!t ” Ci .-* s} ., 73arYi �a7 ':?F;vv i, .^ r 44T -.�, FCl �JrNg1 f'1ir71'3 ?�°t"y' Job Address City __ Lot SizePAe _ PM _ _ Owner's Name �1i ,s / r�IAddress .S �i . ... Phone — - Contractor's Name 1 =f y f0A1S VicenseNo. "° Phone r TYPE OF WELL/PUMP: : NEW WELL ❑ WELL REPLACEMENT ❑ i DESTRUCTION ❑ PUMP INSTALLATION ❑� -.� r SYSTEM REPAIR ❑� t 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 ❑ OpenBottom -❑ Manteca Dia. of Well Excavation 7 Dia. ofWellCasing' I z ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy , 'Type of Casing� � - Specifications ❑ Public E3Other ❑ Delta.. t,t,Depth of Grout Seal _`"# Type of Grout ElIrrigati6in __�_4pprox: Depth .❑ Eastern - Surface Seal Installed by' Repair Work Done ❑ Type of Pump H.P. - State Work Done n Well Destruction ❑ Well Diameter Sealing Material (top 50'1 c(�f Depth Filler Material (Below 50') `' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is --------»-� f available within 200 feet.) Installation will serve: Residence Commercial_ Otger f Number of living units: Number of bedrooms — + Character of soil to a depth of 3 feet: X Water table depth � SEPTIC TANK L►S Type/Mfg _ d!!�A/L.e, .0 Capacity No. Compartments l PKG. TREATMENT PLT. ❑ ,.. / Method of Disposal 1 Distance to nearest: Well 'Foundation /L( Property Line ow LEACHING LINE No. & Length of lines Total length/sizeze FILTER BED ❑ Distance to nearest: Well;1W f Foundation 2fi' Property Line f � '17__�._ Number 3 - SEEPAGE PITS [Depths Size -� P T "SUMPS ❑- Distance to nearest: Well ZE s 'Foundation Property Line DISPOSAL PONDS ❑ r 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 District: Y 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 laws of California."Contractor's hiring or sub-contracting signature ' certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ,tion laws of-California=' -- - s The applicant MRt call for all required inspections. Complete drawing on reverse s . Signed Title: Date: — E FOR DEP MENT USE ONLY -Application Accepted by' Date �fI Area Pit or Grout Inspection by Date Final Inspection.by Data iAdditional Comments: ❑ Stk 466-5781 4- ❑ Lodi 359 621 ❑ Manteca 823-7104- ❑ Tracy 635-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.;CA SM1 t ' FEE AMOUNT OUE�, � +�IOIOtJNT RE�V0.11TT�D CASH'�"fRECEII/Ei5 Bl'"'�'"`• �`""""D/1TE ""PERMIT"N0. 7 INFO + EH 13-24(MV.101831 �7 EH 10-4.28