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f.erJnt•y?.p— n.�� -.T..-�. I APPLICATION FOR PER'IMIT � f SAN JOAO,UIN.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 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 '� r Job Address Lot Size / PM _l. E' /' L� (((�� 84/ Owners Name Address .a Phone x + Contractor Address - ' License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION}SPECIFICATIONS I ❑ Industrial ❑ Open Bottom 171 Manteca ,t Dia. of Well Excavation Dia. of Well Casing ill 1:1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of.Grout Seal Type of Grout i' ❑ Irrigation .....K ' i'—Approx. Depth ❑ Eastern Surface*Seal Installed by f Repair Work Done ❑ Type of'Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 .,� . Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is_ , _ �. available within 200 feet.) 7 Vi I Instbilation will serve: Residence_ Commercial_ aOther Nurl ber of living units: Number of bedrooms v e r Character of soil to a depth of 3 feet: !° Water table depth v SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG..TREATMENT PLT. ❑ Method of Disposal ' tf I Distance to nearest: Well Foundation !a Property Line LEACHING LINE 11' No. &'Length of lines r F Total length/size FILTER BED ❑ Distance to nearest: Well Foundation # Property Line SEEPAGE PITS ❑ Depth Size l Number + SUMPS ❑ Distance to nearest: Weil 1 -Foundation w 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..) 1! 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." 7. The applicant must call for all required ins pe tions. Complete drawing on reverse side. ,. .Signed" ,� rrlb --"Title: - r' Date: � f y � FOR DEPARTMENT USE ONLY Application Accepted by r `p Date Area ! {ry Pit or Grout Inspection by Date #-4;- ",Final Inspection by Date 4 i Additional Comments: 41 � � ❑_Stk.E466-6781 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 CA 95201� h�-� C�v FEEAMOUNT DUE" AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 1 -24 PREY. `'�l►! 8�1nb-7 EH 144-26 -.