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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Y t� 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hetaby 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.. �^ff ''d � /,zt� f% /�/. City C.I��Tifrtir Lot Size PM Job Address Owner's Name 0,�e2r1 lze_1149Address / %l / 0,47-/ e�,n/,C/ Phone T Contractor t'tiy�Y6KSa Address /3 y' /��✓�' License No. Phone `9e3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ p PUMP INSTALLATION S- SYSTEM REPAIR ❑ OTHER ❑ -*W A ` .f' a7ir a fly r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP:L1Ng 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4 - - - --: -Specifications _ -1 Public ❑ Other r Delta Depth of Grout Seal, .rL --Type of Grout_- { I Irrigation —_Approx. Depth • I.1 Eastern Surface Seal Installed by'` - Repair Work Done ❑ Type of Pump .f4rh, H.P. 3 "—,State Work Done _ Well Destruction ❑ Well Diamet Sealing Material Itop�50�1 Depth Filler Material (Below 50'1 k r .- . TYPE OF SEPTIC WORK: NEW INSTALLATION I) REPAIR/ADDITION l I DESTRUCTION l 1 (No septic system permitted if public sewer is 1 available within 200 feet.) `Installation"will-serve: Residence Commercial- Other g " Number of living units: Y.r Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 6'--'•Typ_e/Mfg Capacity No. Compartments \ f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line v: LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS - Ll Distance to nearest: 'Well Foundation Property Line , DISPOSAL PONDS ❑ "' �= I hereby certify that 1 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 D!§trict. Home owner or licensed ag `siongture certifies the following: "I certify that in the performance of tha work for which this p rmit is issued, I shall not employ any person in ski n er as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: " certi at in the rfor ce of the work for which this permit is issued, I shall employ peisons subject to workman's compensa- tion laws of Californi f' f0 ' ' 3 `r The applicant m t allyf `r a ire i cti s. Complete drawing on reverse sid d Signed X Title: y Date: FOR DEPARMENT E ONLY aa r c Date Area Application Accepted by Pit or Grout Inspection by Date Final Inspection by. 61-7 Date r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracyk"835-6385 { Applicant - Return all copies to: Environmental Health Permit/Services 1601'E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 E t FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO. INFO / CASH ' �.EH 13.241REV.I/H5; / i S �� UA`14 a EH 14-29 !!! S� -