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APPLICATION FOR.-PERMIT SAN JOAQUIN .LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 y . ;.. . PERMIT EXPIRES 1F YEAR FROM DATE ISSUED ,er�`xa;qzs t1 �, '—'eilltr_19VGDrr111 l':`iU .� `..L. -fk(Complete In Triplicate); i° r 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.:0'-. I1afti #. t Job Address /n Q J` Q �/- - City Lot Size PM Y—Owner's•Name[ r. C..-2.�i ti ,--rte...? Address Phone - — _Contractor's Name r v License.-No, . - ,, l �t Phone 7 w 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 k AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .❑ Industrial ❑ Open Bottom-, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1-1 Domes tic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation —--Approx. Depth ❑ Eastern, Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: ,Residence— Commercial { Other D� Number of living units: Number of bedrooms I p l 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 t- Distance to nearest: Well Foundation Property Line f, LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 'El Distance to nearest: Well Foundation Property Line a { SEEPAGE PITS ❑ Depth 'Si" I Number Y I, SUMPS-. `❑ Distance to nearest: Well- # �'r',Foundation Property line DISPOSAL PONDS' ❑ 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 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 ipermit is issued,I shall employ persons subject to workman's compensa- tion laws of California.",- r The applicant must call fo Il re fired i pec ions. Complete drawing on reverse side � � -- �s0 (11 t Signed r Title: 1-. Date: F # FOR DEPARTMENT USE ONLY Q� � .Application Accepted by' Data C 4w- Area_ + Pit or Grout Inspection by i Date Final Inspection by_v 401V1:'7 A ditional Comments: ry Stk 466-6761 ❑ Lodi 369-3621 ElManteca 823-7104 ❑ Tracy; 835-6385 . plicant,- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,-P.O. Box-2009;Stk., CA 95201 „ b IFEE NFO AMOUNT DUE AMOUNT REMITTED A "' RECEIVED BYY tDArE"' PERMIT"NO. + EH 13-24(REV.10!831 7 EH W26 �. ,: � LI S 1 / � '-Li s7