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i. APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT � . 1601 E. HAZEL T ON AVE.,•STOCKTON, CA 'Telephone (209) 466-6781 PERMIT EXPIRES.1 YEAR FROM DATE ISSUED T• t F l4 , : (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 I Local Health District. " " 1 y Job Address - 9. f`� �f� f�cl% _ City 7'>A Lot Size AQAky"�-&S` PM Owner's Named" '-l7�'��.Y ` " Address S'✓��'- __ W Phone ContractorSG+W Address' �OX � �' License No. � � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r i PUMP INSTALLATION ❑ SYSTEM REPAIR-❑' JOTHER ❑ i DISTANCE TO NEAREST: SEPTIC'TANKSEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED (USE TYPE OF WELL sPROBLEM AREACONSTRUCTIONSPECIFICATIONS ❑ Industrial - ❑ Open Bottom f_1 Manteca f Dia- of Well Excavation Dia. of Well Casing I ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public �1 ❑ Other ❑ Delta Depth of Grout Seal ? Type of Grout I' ,.-.�,-,. n......,.., €Ll Irrigations,,,_ ppi'ox'Depth""'❑"Eastern Surface-seal-Installed by.�..-.-.----. . Repair Work Done ❑ Type of Pump H.P. State Work Dane well Destruction ❑ Well Diameter Sealing Material (top 50'I f ° -1 Depth 1 .Filler Material (Below 50') (TYPE OF SEPTIC•W.ORK:.._NEW-INST•AL-LATION-14--flEPAIR•/•ADDITION-❑—DESTRtfCTION-5-(No septic system permitted if public sewer is l # available within 200 feet.) Instailat on will serve: Res' ence/ Commercial Other 1 Number of living units:, q Number of bed ooms l I Character of soil to a depth of 3 feet: Water table depth r, ,SEPTIC TANK -PC. Type/Mfg �1Je eArl, 61no� Capacity No. Compartments { a,-, _, rPKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line l I LEACHING LINE No&Tlength of lines �a .-._ t Total length/size ►FILTER BED ❑ Distance to nearest: Wel �� Foundation.1 /e � Property 1-11ne 'SEEPAGE PITS ❑ Depth Size - Number j SUMPS t .171 Distance to nearest: Well Foundation Property Line :OISP05AL PONDS ❑ I herebycertify 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. '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 Remploy 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- t ' 'tion laws of California." I The applicant must c I for all required inspections. Complete drawing on reverse side. i I 1Signed X "`c Title: Date: FOR DEPARTMENT USE ONLY F Application Accepted by7Date Asea 10 { Pit or Grout Inspection by to Final Inspection by Date tEa:4; "�/ € t s 1Additional Comments: i. p ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 { !E I7F;Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2w9,',Stk., CA 95201 't FEE AMOUNT.DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. o INFO EH 14-26 r. + EH.13-241REV.i/esl