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;r k APPLICATION FOR PERMIT j SAN JOAQUIN`LOCAL HEALTH DISTRICT 1601 E. HAZE'"TON 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'548 for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health Dist+r/'ict. J� /� Job Address ' City Lot Size z- PM �. Owner's Name - r Address _ Phone �l < Contractor d s y License Nod. O Ptionet � TYPE OF WELL/PUMP:d __NEW WELL ❑ WELL REPLACEMENT ❑ "DESTRUCTION 13�� PUMP INSTALLATION ❑ �.--- SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `_t-DISPOSAL,FLD.�' PROP, LINE t FOUNDATION 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 j ❑ Domestic/Private ❑ Gravel-Pack ❑ Tracy T �� - _ Type of Casing _ Specifications ❑ Public C1 Other ❑ Delta q Depth of.Grout-Seal ,'_Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern ' C Surface Seal,Instiflled by m - Repair Work Done ❑ Type of Pup �H,P: `State Work Done \l Well Destruction ❑ Well Diameter w. Sealing Material (top 501 . . , Depth "y Filler Material (Bela ') > TYPE OF SEPTIC WORK: NEW.INSTALLATION ❑,,,_REPAIR/_ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is E available within 200 feet.) g Installation will serve: Residence_ Commercial , 0th Number of living units: Number of bITAgoo,m j Character of soil toga depth of 3 feet: Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments b + _ y r PKG. TREATMENT PLT. © ` k°� Method of'Disposal 11 Distance to'nearest: Well Foundation Property Line ` J LEACHING LINE I,-"No. & Length of lines Total length/size s FILTER BEA ❑ Distance to nearest: Well Foundation 2-D Property Line SEEPAGE PITS ❑ Depth 2 ) Size _Number -SUMPS ❑ Distance to nearest: Well Md 70L Foundation )r Property Line.__ f DISPOSAL PONDS .. ❑ N + € 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, 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:Yl certify that in theperformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California:"`� ,�o The applican must call f all requires inspections. Complete drawing on reverse side. Signed Title: f r Date: kal-Sq , FOR DEPARTMENT USE ONLY Application Accepted by Date 3 Area 6 2> { Pit or Grout Inspection b Date �� Final Inspection by Date # �Ad�itional Comments: Ly(Stk 466-6781 El Lodi 369-3621 EJ Manteca 823-7104 ❑ Tracy 835-63E35 ; Ap ),cant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE t I INFO AMOUNT DUE AMOUNT REMITTED 'C K _ RECEIVED BY DATE PERMIT'NO. + ASH EH13-241REN.t7e5i --.--•-. �.p�•,,.-.,.....-.<,-.. ,..+.--- .. --.w-- - ..`. -�-r^-,y-"'t"^---+....--+.. .,�.r ,/7J�]�.�.-,:«w- w•w�+.-�r-�'.. EH 1426 V f f'