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i ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone-12091"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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin 'Local Health District. "i !u - . 1 �1� •�':,,y ,./. ! ,.sr �J��: �,ti�, tr a�.. � _'k..`�4,�:. I� ��W�� t.'„ „ .,�sr, 17��J s41L� ,,, •.k, , ;, ^ >_ Job Address C City' Lot Si ) C�.. 13 6C� c Owner's Name �-• Address -�f�% �-,/ •C�.�� rJ�� Jd� Phone=-- Contractor -( /[u � � Address /?a �� License No.��S'. �L Phone -� c TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ # PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION WELL OTHER WELL f PITS/SUMPS f _ INTENDED.USE TYPE OF WELL PROBLEM AREA H CONSTRUCTION SPECIFICATIONS ❑ Industrial # ❑ Open Bottom ❑ Manteca Dia: of,Well Excavation Dia. of Well Casing 41 13 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 11 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout' s ❑ Irrigation . i g t pproz. Depth El Surface Seal Installed by Repair Work Done ❑ pe of Pump H.P. State Work Dane Well Destruction ❑ -Well Diameter Sealing Material (top 50') w Depth Filler Material (Belo 50') r TYPE OF SEPTIC WORK: 'NEW INSTALLATION ❑ REPAIR/ADDITION Iff DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.), Installation will serve: R sidence_ Commercial_ Other f N Number of living units: -I' — Number of bedrooms fi f i a Character of soil to a depth of 3 feet: Water table depth o2O SEPTIC TANK + ❑ Type/Mfg ' Capacity ,t No. Compartments PKG. TREATMENT PLT. 0" r � `Method of Disposal Distance to nearest: Well Foundation F 1� Property Line �. LEACHING LINE ❑ No. & Length of lines '` -'Total length/size FILTER BED tl� Distance to nearest: Well Q Foundation!Y,4_ Property Line SEEPAGE PITS! ❑- Depth Size !1-Number C SUMPS ❑ Distance to nearest: Well i Foundation£ rProperty Line DISPOSAL PONDS ❑ I 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. )= r 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." 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 shall employ persons subject to workman's compensa- tion laws of California." r R The applicant must call for alJovequired Ispections. Complete drawing on reverse side. I Signed ` r Title; X i Date: /11 06 � - .. ..+ V Lff -. -14. ! .. —.-- FOR DEPARTMENT-USE ONLY- W L Application Accepted by Date _�b-7�0 Area j i r, Pit or Grout inspection y Date Final lnspection by Date �� Additional Comments: r "4' i ❑ Stk 466781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tr'acy-835.6385 ' Applicant- Retm- all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ava_, P.O.`Box 2009, Stk., CA 95201 rEEINFO AMOUNT DUE AMOUNT REMITTED GASH ,, �RECEIVED'BY DATE PERMIT"NO. + EH 13-24(REN.1/e 5) _A 1 C EH 1428 L1 J, C:) 3 '