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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 LJ tee—!. EXPIRES YEAR FROM DATE ISSUED P P PERMIT EXPI1(Complete in Triplicate) 1 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 Local Health District. Joh Address C'ty Co'I—ze PM 1 Owner's Name Address ��- P Phone { l Contractor � r Addres. /I<.T�.. Gtr e � License No��Phone 4 ` TYPE OF WELL/PUMP: NEW WELLT0 - -WELL REPLACEMENT ❑ I DESTRUCTION ❑ PUMP INSTALLATION L71-- .-' SYSTEM REPAIR 4A. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATiONf` AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrials ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications __ i Public H Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx.+Depth { I Eastern Su ce Seal Installed by. Repair Work Done Type of Pump S» H.P. State Work Done w-� Well Destruction ❑ Well Diameter Sealing Material (top 50') ' Depth r Filler Material I8elow 50') TYPE OF SEPTIC WORK; NEW INSTALLATION (1 REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is % available within 200 feet.) Installation will server Residence Commercial_ _Other s % { Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK v ❑ Type/Mfg �' '" Capacity . No. Compartments PKG. TREATMENT PLT CI 1 -7 -' N Method'of Disposal`. Distance to nearest: Well `,.Foundation Property Line LEACHING LINE ❑ +Nod`& Length of lines ~ Total length/size . FILTER BED ❑ Distance to nearest: Welles Foundation Property Line l SEEPAGE PITS I I Depth Size ¢ Number .ed 1 SUMPS Cl Distance to nearest: Well Foundation Property Lineal DISPOSAL PONDS ❑ r 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 Joaquiri Local Health District. y" _ Home ownei 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: "I certify that in the performance of the work for which this permit is issued, I shall employ-persons subject to workman's comp nsa- tion laws of California." i ,.r' Yt The appli mu call for all Ired spec' s. Complete drawing o rse side. Signed X cr Title:� _ �" Date: J94Aor-f 1 ORD ARTWNIJJ&EONLY S��V i Application Accepted by —//-- Area f Z- Pit or Grout Inspection by k Date Final Inspection by Date Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE INFO AMOUNT DUE r AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 4 ' +.EH 13-24(REV.r/Kbi _ EH 14-28 �q o- i