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' I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 li 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. {!' Joh Address l b C�D0/-1 D G City S7 r at Size PM 1 5 p1,�f eA v [.a5 f�l'las r 1 Owner's Name ��brlSLi��s� _ Addres Phone I _ _ -363Q4911 n Contractor's Name fi License (D No. 3'7 j ` ~' ` Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑' DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES —7DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private F1 Gravel Pack ❑ Tracy Type of Casing Specifications { ❑ Public ❑ Other O'Delta Depth of Grout Seal Type of Grout Ll Irrigation �pproxIDepth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ *Type of Pump, H.P. State Work Done Y U i Well Destruction ❑ Well Diameter r Sealing Material (top 501 h ,r Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION II "--DESTRUCTION ❑ iNo septic system permitted if public sewer is 1A 1 t available within 200 feet.) Installation will serve: Residence': Commercial_ Other Number of living units: Z Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth # s SEPTIC TANK t ❑ Type/Mfg eonL Capacity No. Compartments hPKG. TREATMENT-PL-T. ❑ ^ Method of Disposal Distance to nearest: Well - foundation Property Line T ' _ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C1 Distance tonearest: Well Foundation PropertyrtY Line .t w SEEPAGE PITS ,Depth 25 L r• -Size' 01 Number 0 n XPi SUMPS ❑ Distance to nearest: Well-1119 — Foundation A Property Line DISPOSAL PONDS ❑ r 3 1 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. Home owner or licensed agent's signature certifies the following:.'I car6fy 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." The applicant ust call for all in tions. Complete drawing��'00 Signed ��' Title: Date: �� f -FOR DARTMENT USE ONLY {y f Application Accepted by Date d ~ / Pit or Grout Inspection by Date Final Inspection by Date Additional Comment ., ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E.rHazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO CASH Li E + EH 1324(REV.101831 ��, 1l 3 I� "q q EH 1426