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� t e APPLICATION FOR PERMIT LI_ ba SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA k s Telephone (2091 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.549 for sewage or No. 1862 for well/pump and the.Rules and Regulations of the San Joaquin t ocai Health District. ,j, Job Address > '"- �r✓�� k City Lot Size PM Owner's Name /� >n! I A.,j�RgEZLg ddress .1-1-L4Phone Contractor K 7 _Address License No.�&. Phone I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. �� PROP. LINE r FOUNDATION AGRICULTURE WELL_-- OTHER WELL ,�, � PITS/SUMPS L % INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation >lin– Dia. of Well Casing Avbomestic/Private ravel Pack ❑ Tracy Type of Casing pelc1 Specifications F1 Public 17 Other Ll Delta Depth of Grout Seal 1AP-0 Type of Grout _ I I Irrigation Approx. Depth i I Eastern Surface-Seal Installed by //K��/c• ` ��f _ Repair Work Done ❑ Type of Pump H.P. f State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'I _ TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No_ Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." - The applicantsit r uired Complete drawing on rev side. II Signed X irk Title: Date: FOR DEPARTMENT USE ON/Ly q Application Accepted by Date iArea Pit or Grout Inspection by Dale e Final Inspection by L% Date Additional Comments PA t7(/� ZZ 0cc C3' S S ❑ Stk 466-6781 o M69-3621 anteca a23-7104 ❑ T acy 835-6385 r Applicant - Retur copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH CK A RECEIVED BY DATE PERMIT'NO. r r. EH t4-11 EH 13-24 iREV.I/n 51 '�` �b�v. '� � ; ]� 0-16w J p