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APPLICATIGN FOR PERMIT SAN JOAQUIN LOCAL'-WALTH DISTRICT ' 1601 E. HAZELTON AVE.,"STOCKTON CA, Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f 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.complianco 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. R Job Address 1 "� ► City Lot Size PM Owner's Nama U l.W Address � 1/" � L Phone Contractor 'f-�= r�rtr'i/t� ' Address 3 �..} ry , License No.Zi?Qn PhoneLn_f 2. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:"SEPTIC TANK SEWEN LINES`? DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC LTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE /CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca �= Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specrfications I'1 Public ❑ Other F1 Delta Depth of Grout Seal _ Type of Grout__ 1 I Irritjiitli n __,Approx.,Dc•l:)4h i i £astaril � su liiGfS �,tD:i,1n.8 — Repair Work Dane El Type of Pump H.P. ? State Work Done Well Destruction. C1 Well Diameter Sealing Material (top 501 4 Depth Filler Material (82W 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION A DESTRUCTION i (No septic system permitted if public sewer is r'^ l� a ag b!� thin„�fJo'feet•) ,� L Installation f will gserve: Reside nee_ Commercial L, 7 5�� - ` / Number of )ruin units: Number of bedrgomsj (� +� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg r opacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line ! LEACHING LINE ❑ No. & Length of lines r 7 r tal length/size FILTER BED - ❑ Distance to nearest: WVJT Z Foundation Property Une` SEEPAGE PITS I I Depth Size Number (� SUMPS Ll Distance 4`to nearest: Well� e Foundation /i1 Property Line DISPOSAL PONDS ❑ 4 I hereby certify that 1 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 �r employ any person in such manner as to become subject to workman's compensation laws of California.” Contractor's hiring or sub-contracting signature_1F> s 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--ia tion laws of California." The applicant must calffor all required inspections. Complete drawing on reverse side. Signed f r'' e, Title: Dater f " , .✓ }.. r FOR DEPARTMENT USE ONLY 1 f G I Application Accepted by Dat ,` J�� Area ? Pit or Grout Inspection by _ Date Final Inspection by_G - 1�`r�rs - Date Additional Comments: 11 ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. aox 2009, Stk., CA 95201.FEE N�` INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVE 8Y DATE PERMIT'�iNO. `. . +,EH 13.24(Kv.tins) '1 } '-- l' ,••• /� _ -((p!!