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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON.AVE., STOCKTON, CA Telephone (209) 466-6781 S 007 R 4/V (' PERMIT EXPIRES 1 YEAR FROM DATE ISSUER„ Q& �u 119,(Complete in Triplicate) f�Rp„� ,�GyfG�,y � JA ' G Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here., _f sCrjb �i'9}application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regu)'a6q<gt �fIll)epn Joaquin Local Health District. UUP/s I� f ` 'ail, I Job Address �` City �` p Lot Size PM I Owner's Name Address l 51 r Phone Aq Contractor - I � Address ��ks Al �I� WD5 C License No.Q`�Phone 3�9Z 39 TYPE OF WELL U NEW WELL D 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 PITSISUMPS 1 INTENDED USE TYPE OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS- Dia. PECIFICATIONS ❑ Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' IN Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-I Public ❑ Other F Delta Depth of Grout Seal Type of Grout i I Irrigation --Approx. Depth 1.1 1.1 Eastern Surface Seal Installed by - _ Repair Work Done L� Type of Pump S— H.P. r State Work Dane 7-7-A/ �� m Well Destruction ❑ Well Diameter Sealing Material (top 50'1 L A/S J/ 908 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well +Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size j FILTER BED s ti. ❑ Distance to nearest: Well Foundation ' Property Line SEEPAGE PITS I I Depth Size _ Number 1 SUMPS Ll Distance to nearest' Well Foundation Property Line DISPOSAL PONDS ❑ --1 hereby certify-that I have prepared thisapplicationand that the work will be.done in accordance with San oaaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D11trict. � I 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: "1 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 applican must call f 11 required n-inComplete drawing on reverse side. Signed X Title: Date: F R DEPARTMENT USE 4LY Application Accepted by Date 0 �b�'I — Area Pit or Grout Inspection by Date. Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ 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 2009, Stk., CA 95201 ` FEE A OUNT DUE AMOU REMITTED K REC IVED BY E PERMIT NO. b I O +.EH 1324(REV.r i H 5) -�- EH 14-2a