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.w ..�, s .. ... y .. i ,y r L. I i f:b-/.. f ..a51+s-r ,r Iiu.•lw L r}y.�.v F A' ¢. .. M, � –„ --- . —' —� APPLICATION FOR PERMIT ' t _ SAN JOAQUIN LOCAL HEALTH DISTRICT k ' 1601 E..HAZELTON AVE., STOCKTON, CA, Telephone (200) 466-6781 _+4__ PERMIT EXPIRES 7 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 Rules and Regulations of the San Joaquin Local Health District., Job Address � , t ,_ f �� d�./ City Lot Size PM Owner's Name s t�/U EO.W C2&,3rAddress Phone "`� cyz w---- \, Gv/ Y /20 Contractor d4&42 / S _—J Address_2Z.,Zc* (, �� License No. Phone ` TYPE OF WELL/PUMP:. t.,,.. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ t r' DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINE 3?)+ FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS uV ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing kMomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern c Surfac Seal Installed by ' Repair Work Done ❑ Type of Pump H.P. %1_- T_ State Work Done_j/.1L, la / Well Destruction ❑ -Well Diameter Sealing Material (top 50'1 /N /SCS_ mak/5T/.V/ LU,� Depth Filter Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system _ p permitted if public sewer isy available within 200 feet.) 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 ElType/Mfg Gapacity No. Gompartments PKG. TREATMENT PLT. El 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 SEEPAGE PITS, ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." The applicant mu f r II required inspections. Complete drawing on reverse jocle. v p Signed Title: Date: FOR DAP4WTMEN USE ONLY L Application Accepted by A Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: IZ ! >* i�7_—�7, k� _ ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' h FEE INFO AMOUNTT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24(REV.I/a 5) J EH 1428CZYA!�___