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APPLICATION FOR PERMIT 1 SAN JOAQUIN,.LOCAL HEALTH DISTRICT � 1601 E. HAZELTON AVE.,-STOCKTON, CA " 'Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUEDfi ?f `(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 Rules and.Regulations of the San Joaquin Local Health District. 17� Joh Address / �/��u// UUClomCity, Lot Size ! PM Owner's Name'—ST: C o b "Address Phone f Contractor LE_ L�T-I_!'a dress s� L� I cense No. _ hone_ 1 TYPE OF WELL/PUMP: v,.? NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ A , DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE-OF.-WECL--' 'PROBCEM AREAL—C-ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other O Delta i Depth of Grout Seal Type of Grout ❑ Irrigation ___Approz:!Depth. 1171'Eastern '- - Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction -❑ Well Diameter Sealing Material (top 501 r Depth Filler Material. (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is availablelwithin 200 feet.) Installation will serve: Respence Commercial_ Others � ' Number of livingunits: Number of bedroomsc Character of soto a depth of 3 feet: .__ ��L C_� ) _ ` Water table depth SEPTIC TANK ❑ Type/Mfg ► Capacity No. Compartments , PKG. TREATMENT PLT. ❑ t $ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE GNU. & Length of linesd - Total length/size° FILTER BED ❑ -Distance to nearest: Well lMt Foundationsd7 Pro ert line SEEPAGE PITS L;--f3-epth Size Number SUMPS ❑ 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 District. T_- �.� + !. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of thework'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 lbws of California." The applican t call•for Ire cared'1 ctiACpiete drawing on reverse side. T�Signe Title: �( /Y'� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r Area 0 1 Pit or Grout Inspection by Date f-'t - Finalilnspection by Date G � Additional Comments: _- Stk 466-6781 ❑ Lodi 369-3621. ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO C H -+ EH 1344 OtEv.Is) H -- - `- EH i4-28 _ br /0 /; I �' '_ r "'(/�S�p �