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APPLICATION FOR.PERMIT j �►/` Cie,* ��'�L� SAN JOAQUIN LOCAL HEALTH DISTRICTh4k "' �:� �p • 1601 E. HAZELION AVE., STOCKTON, CA 01 , 5 e )Il Telephone (200) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 c Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tthh�ork herein described.T I' This app kation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and th Rules and Regulations of the San Joaquin Local Health Distr0 P e 1`'�k c1r 4S 4 Al# �'o sA fa 1"` a ,1` t. Job Address t . Lot Size PM csL9"S�' CG t4.1-V4r Owner's Name Addressbne yA�,�j Contractor )6<4 JO e 15 #Tddre�s� License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ . DESTRUCTION ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ( FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications � F-1Public ✓cher © Delta Depth of Grout Seal Type of Grout �. Yet r El . Irrigation ---Approx. Depth ❑ Eastern r�r�/ Surface Seal Installed by Repair Work Done ❑ Type.of Pump C°t'�-+�+ 1i.F.0 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Materia! (Below 501 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will s Residence_ Commercial_ Other Number of living units: mber of bedrooms 7(1 Character ofs oil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foun Property Line r LEACHING LINE ❑ No. &Length of lines Total leng r l FILTER BED ❑ Distance to nearest: . Well Foundation Propertytine i SEEPAGE PITS © Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line J 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 c, i rules and regulations of the San Joaquin Local Health District. k 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 notes employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 ap lic t m call for all re Ired inspec' s. Com a drawing o erse side. Sign Title: �/T Date: — // FOR DEPARTMENT USE ONLY ry Application Ac p by v Dat �'0�� Pit or Grout Inspection by Date Final Inspection by ' Date s` Additional Comments: ` ❑ Stk' 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Retuin all copies to; En 'ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., A 95201 2� GGae. d-•t3fFEE INFO it AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PEftMIT'NO. 4 i + EM 13-24 EH 1428;REV.1/8 5)