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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH•DISTRICT L 1601 E. HAZELTON AVE.,-STOCKTON, CA Telephone (209) 466-6781 I� l PERMIT EXPIRES 1'YEAR FROM DATE ISSUED L% (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 scribed. his lication is made in compliance with San Joaquin County'Ordinance No.548 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. 4 Job Address I q City S'aC a Lot Size PM a Owner's Name .M., 7S O YAddressi v -Phone t\l Address r 1 * �`� �+�`�� ense No. �77.. ' O Phone Sa Contractor in TYPE OF WELL/PUMP: NEW WELL.0 WELL REPLACEMENT ❑ DESTRUCTION © ' i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑• 07HEii'❑t; . tf DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAU FLD. PROP.,,LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Llfindust ial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation x Dia. of Well,Casing ❑tDomesti /Private " ❑ Gravel PackS. ❑ Tracy • Type of Casing Specifications 3 FI Public ❑ Other ❑ Delta, Depth of Grout Seal Type of Grout _ {q I t1m.auon __.Approx. Depth' I i Easterrit. SLA ca Seal'lnstalled:by. r1. .> r "�Repair;Work Done ❑ Type of Pump H.P.. State Work Done Well'Destruction_ • ❑ Well Diameter Sealing Material (top 50') Y. Depth Filler Material (Below 501 "3" TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is j t i available within 200 feet.) Installation will seriio:' Residence— Commercial_ Other :"" ` Number of)iving units: Number of bedrooms kk . c Character of soil to a depth,of 3 feet: Water table depth a SEPTIC TANK-. . _ ❑ Type/Mfg- Capacity No. Compartments � # PKG. TREATMENT PLT. ❑ ,Method of Disposal_ Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of.lines . Total length/size t F FILTER BED ❑ Distance to nearest: Well Found4tion Property.Line SEEPAGE PITS I I Depth SiiYe Numbers .T SUMPS LT Distance to nearest: Well" Foundation .Property Line � 5 DISPOSAL PONDS ❑ k,Y Thereby certify that I have prepared this application and that the'work will be done in accordance with San Joaquin county ordinances, state laws, and r rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which.tIkis permit is issued, I shall not employ any person in such manner as to become subject to workman's corn ensaiiion laws of California." Contractor's hiring or sub-contracting signature f certifies the foltowing: "I certify that in the performance of the work for which this permit is issued, ['shall employ persons subiect to workman's compensa' tion laws'of California." The applicant,must call for all req d spect+bn Complete drawing pn reverse side: (� Si�ried Title: '�w . ' t ` � ••Dale: ' F DEPARTMENT USE ONLYS N^_ Application Accepted,by Date. �� Area t/ Pit or Grout Inspection by D te' Final Inspection byDate Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑Manteca 623-7104 ❑ Tracy 835-6385 Applicant_Return all copies to'Environmental Health Permit/sfiNices 1601 E: Hazelton Ave., P.O. Box 2009, Stk.,;CA 85201 } ' f FEE AMOUNT DUE AMOUNT REMITTED r CK RECEIVED BY DATE PERMIT'NO. INFO I fCt 11 + EHS3-24{rtEV.rin51 � `-rt.}U 'f �� Ude l '�4� �� V �+� •"I!� e� EH 14-26 1