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APPLICATION,FOR PERMIT &//t O 376 SAN JOAQUIN:LOCAL,HEALTH DISTRICT li 1601 E. HAZELTON AVE.,zSTOCKTON, CA Telephone{209} 466-6781 .s . - 1 . ., (•T"•!l.'.:• '� }•.t .i y..�... Y S: a. n PERMIT EXPIRES•1 YEAR FROM DATE.ASSUED . (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.TMs application is ' -made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of the San Joaquin Local Health District. ` ' Job Address /� ,[ �7` Or 6- �C.. City. _ AC -Lot Size_ //,�-. p(y1: '• Owner's Narrleu D. 041, :y Address Phone_ _ Contractor License Noei;t��:Ks A-n=i Phone TYPE OF WELL/PUMP: ,NEW WELL ❑ WELL:REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC;TANK SEWER LINES DISPOSAL FLD.. PROP.!LINE 1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF:�WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! \ ❑ Industrial ❑ Open Bottom 17J Manteca Dia. of iWell'Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing � j Ll Pub f g r g t Y Specifications ❑ Other i ❑'Delta ,Depth of Grout Seal 1 Type of Grout ❑ Irrigation y Appro�xli, Depth ❑ Eastern SurfacePSeal Installed by f Repair Work Done ❑ Type_of;Pump H.P. t 1 State Work Done_ # Well Destruction ❑ Well Diameter Sealing Mate'rial"ttop 5011 r ,�e t f Depth '.9 Filler Material iBelow`5{)'1 TYPE OF'SEP7ICWORK: NEW iNSTALLATIO REPAIR/ADDITION- ❑€ DESTRUCTION ❑ (No septic system permitted if public sewer is P available within 200 feet.) Installation will serve: Residence � i a _ Commercial Other �. S. .-M1•, -: air _- - _ i- K—s"�•t` --�vS`._y,..=a.: ,- :_T .A - ... :.�- - C Number of living units: Number of bedrooms Character.of,soil to a depth of 3 feet: A U " : I , ;! .; i .v - Water table depth SEPTIC-TANK ❑ Type/Mf' L g Capacity ) No- Compartments j PKG. TREATMENT PLT. ❑ II� Method}of,Disposal Property Line # Distance to nearest: Well Foundation)=�0 y 1 LEACHING LiNE i No, & Length of lines W oc Tyotal length/size CIO FILTER BED 1 ❑ Distance rto nearest: Well foundation* Z92 Property Line SEEPAGE PITS i 0 Depth' r Size_ t ': Number ,SUMPS i ❑ rNstance to nearest:• Well Foundation Property Line DISPOSAL PONDS ❑ 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 l rules and regulations of the San Joaquin Local Health District. i � _ Home owner or licensed agent's signature certifies the followin certify pe I r p t employ an 9 "I certi that in the rformance of the work for which this ermit is issued, I shall not p y person,in such manner as t l become subject-to workman's-cohipensation.laws of California." Contractor's hiring or sub contracting signature certifies the following:"I certify that in the pekormance of theiwork for which this.permit is issued,I shall employ persons subject io workman's compensa- tion laws of California." } t The applicant must call V a!Ir quired inspections. Complete drawing on reverse side. g SignedTitle:. �—111r- Date: FOR DEPARTMENT USE ONLY4 i Application Accepted by } Date X � Area i ! i - ; Pit or Grout Inspection by i ; Date Final Inspection by t Date Additional Comments:,x ❑ Stk 466-6781 '; ❑ Lodi 369-3621 i. •O Manteca $23-7104 ❑ Tracy 835-6385- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O: Box 2009, Stk., CA 9520] t. g �� p k+ --w.�.��v'--.- - --5--t--K- T.-a.t�_layy '.r.`.�._.e.+e...w,. - -wrv.q..—..--�-r....y-..-.• ..v.�.�...�+._-......-+-+aF_—.+r-Sx._. _._. - F FEE d INFO 'AMOUNT DUE �� AMOUNT REMITTED 'CK RECEIVED BY CASH - �,1PATE rPPEERRMITT'NO. EH 3-24 e+:EH 14-28(REV.