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APPLICATION FOR PERMIT SAN JOACIUIN.LOCAL HEALTH DISTRICT " 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781' 14 _ PERMIT EXPIRES-I YEAR.FROM DATE ISSUED^ .Z..w.a. . ... �ti:,;-. ., �ih�tl' jComplete-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 incompliance with San Joaquin County O_ rdinance No:549 for'seWage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District,,,,,,,,., st to e' j7 Job Address _ City ..Lot Size PM_ Owner's Address a� . ' � 1/r.'h . Phone . Contractor's ame r�ss 'S� License:uNo:�%• �,- -��• Phone TYPE OFWELL/PUMP:: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIIO � N -� 71 [ISYSTEM REPAIR OTHER A99, i DISTANCE TO NEAREST: SEPTIC TANK & — SEWER LINES 41 DISPOSAL FLD. PROP. LINEc271—ti a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE. TYPE-OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial 1106pen Bottom-. ❑ Manteca Dia. of Well Excavation Dia, of Well Casing n _ `" ype of Casing Specifications v L�"ifomestic/Private El Gravel Pack :E3 Tracy T, � S^' Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - il�rrigation •' = Approxi Depth -❑ Eastern Surface Sea! Installed by S-� ;Repair Work Done ❑ Type of,Pump ._t a H.P. A. State Work Done +Well Destruction ❑ Well Diameter Sealing Material (top 601 Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION F1 ,DESTRUCTION ❑ (No septic system permitted if public sewer is " """t 7 � available within 200 feet.i Installation will serve: Residence_ Commercial_ Other Number of living units! Number of bedrooms_ ra- +, }• ,, .. Character of soil to a depth of 3 feet: '�� .�. '* � � - Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity {° No. Compartments -PKG. TREATMENT-PLT. ❑ }_ 3 i « + N { Method of"Disposal ;. -Distance to nearest:'"' -'Well Foundation `"'*p Property Line LEACHING LINE ❑ ?No. & Length of lines `'',Total length/size . FILTER BED ❑" 'Distance to nearest: Wellg Foundation'' ' - Property Line SEEPAGE PITS *. ❑ .Depth Size _ Number SUMPS ❑"tDistance to nearest:' Well Foundation r Property Line r DISPOSAL PONDS ❑ ' f I hereby certify that I have prepared this application and thet 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."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." i The applicant must call for all quired inspections. Complete drawing on reverse side. ' -The �' i� . Title: = Date: A4 (r FOA D PARTMENT USE ONLY #1 r w �� li" �. Application Accepted by ° F Date Area �¢ Pit or ro Inspection by ? Date FinalInspectionby Date Wit}•'s ` i Additional Comments: ❑ Stk 466-6781 ,. {❑ Lodi 369-3511 -© 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 • r . } :des FEE r' - �gMOUNT DUE `" AMOUNT REMfTTEDGICIN RECEIVED BY DATE PERMIT"NO. G INFO 'CASK EH 13-24 1RE .10!83) ' - .. �. !! -� I� '. {�G,�+` -� ' -6"7� a i EH 14716 �� 1 - s .1 ♦ .��-7 117 !..t"r U