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APPLICATION FOR PERMIT A; SAN JOAGUIN LOCAL HEALTH DISTRICT MIA � n 1601 E. HAZEL T ON AVE., STOCKTON, CA U Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 198 (Complete in Triplicate) OAS 2ki I Application is heieby m de to the San Joaquin Local Health District for a permit to construct and/or install the work h 4T on I' is made in compliance with San Joaquin County Ordinance No.549 for sewage or No..1862 for well/pump and the Ru� 'Sxn.Joaquin Local Health District. h ' Job Address �� l�P pf717 �4 h "m ty 0 Lot Size_ 1w, PM 3 f � � .d� � Owner's Name �[�`Ir'!�� Address L 7 7" 1�� . L-�,� Phone a� �7�.c 7 Z 7. S"03S" Contracto 41 ' + / -L.. �'�� 3 1iEq Phone Q Address License No. TYPE OF WELL/PU P: _ NEW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:"SEPTIC TANK '"== —"; "SEWER LINES DISPOSAL FLD.'. PROP._LINE i FOUNDATIONi�'"`" AGRICULTURE WELL. - OT_HE_R_WELL _ � - - �:...,_. _ v� PITS/SUMPS, j INTENDED USE y TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! s .. L1 Industrial Open Bottom *❑ Manteca Dia. of Well Excavationpia. of Well Casing E 1: 4 XDome.stic/Private [_1 Gravel Pack El Tracy Type of Casing Specifications,. I'1 Public; 1-7 Other � FlDelta Depth of Grout Seal Type of Grout rk I I Irrigation Approx. Depot -1 1 Eastern Surface Seal Installed by �' Repair Work Done ❑• Type of Pump ' '" H.P, £ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 50') F TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted f"public sewer is I available within 200 feet.) 'i Installation will serve: Residence_ Commercial_ Oth �- Number of living units: Number of bedrooms _Character of soil to a depth of 3 feet: YWater table dep Capacity No. Corrtpartments�' th SEPTIC TANK ❑ Type/Mfg " ~ "�Id: j. ; PKG. TREATMENT PLT, ❑ .T Method of Disposal istance to nearest: Well Foundatio Property Line { f - a k�i EACHING LINE ❑ No. & Length of lines Total length/size -k-'FILTER BED ❑ Distance to nearest: Foundation Property Line f "SEEPAGE PITS I 1 Depth size Number { ` = SUMPS.0 nce.to-nearest Well Foundation__ — Property Line +-.... ... " DISPOSAL PONDS '1 ; 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. i 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that.in the pertotmance of the work for which this permit.is issued,_Lshall employ.persons subject.to.'avorkman's compensa- tion laws of California." F The applicant mu" f squired in ctions. eta drawing on reverse side. j Signed X i Title: ., Date: / •[�4 r FOR DEPARTMENT USE ONLY � l Application Accepted by Date �✓y Area i Pit or Grout-Inspection by Date _ Final Inspection byDate i _.. -..Additional.Comments: L .� -•^ {.-.,nom __ I ❑ Stk 466-6781 ❑ Lodi 369-3621-3621 �❑ Manteca 823-7104 ❑Tracy 83 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P..O:Box 2009" Silk CA 95201FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. '+ EH 1324(FtEV.1/n51 EH t4-2e [