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I t } APPLICATION FOR PERMIT r P�U�R � � / SAN JOAQUIN LOCAL HEALTH DISTRICT U 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) y q p application is ' Application is heleb made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This app� i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weil/pump and the Rules and Regulations of the San Joaquin Local Health District. i G Job Address City Lot Size PM Owner's Name �I !'� Address 80?, dt/�J�• Phone 0 3 4 Address Z �.Sr /'t r S Phone Ad $ r� Contractor �� License No. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER X 3 M-M Jq f I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE�� r FOUNDATION 511 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , !y El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `t Type of Casing h D A&C Specifications r� 0 Domestic/Private ❑ Gravel Pack ❑ Tracy YP 9 1/ nPublic Cl Other n Delta Depth of Grout Seal Type of Grout I Irrigation _..Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done 11 Type of Pump H.P. State Work Done _ t Well Destruction ❑ Well Diameter Sealing Material (top 50'1 t Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION i l DESTRUCTION E I (Nailableo septttwihin m emitted it public sewer is eet i Installation will serve: Residence_ Commercial— Other 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 PKG. TREATMENT PLT. ❑ Method of Disposal" Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS l I Depth Size Number i SUMPS Ll Distance to nearest: Well Foundation Property Line 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 Di§trict. 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 I 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." The applican u call for all required i pe tko s. Complete drawing on reverse side. �U0 �Q Signed X Title: Date: - - FOR DEPARTMENT USE ONLY ¢ Date—10—1/!aArea Application Accepted by /f Pit or Grout Inspection `� Date,4 & Ze .i0 Final Inspection by � Dated/ Additionai Comments: b f"1 p-f`W. ❑ Stk 466-67131 Lodi •3621 ■ Manteca 823-7104 Q Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO / �J ..EH 13-24 IREV.1/85} 7f"-- EH 14-29 !