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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1 YEAR FROM DATE ISSUED n (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 Local Health District.,. t US lc%_ s d Job Address lG City / Lot Size PM Address Rhone t - Owner's Na-` —AI Contractor's Name g ".S SAM& License No. Phone i TYPE OF WELL/PUMP: NEW WELL �b WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION la SYSTEM REPAIR Ll OTHER ID '/ / DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION � AGRICULTURE WELL - OTHER WELL PITS/SUMPS iNTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d� ❑ Industrial C1 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing Domestic/Ptivate Gravel Pack E3 Tracy Type of Casing: y AV Specifications e"L _❑.Public ❑ Other ElDelta Depth of GroutlSeal 10L� ape of Grout N ❑ Irrigation P&2&pprox. Depth ❑ Eastern S,,uqgce Seal Installed by - Repair Work Done El Type of Pump �sGG.L.-. H.P. State Work Done -Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public seeker is; i. 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 T) SEPTIC TANKI ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 71Method of Disposal { s distance to nearest: Well Foundation Property Line I ttt LEACHING LINE ❑ No. & Length of lines Total length/size ; FILTER SED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS ❑-'Depth Size + Number SUMPS ❑�Oistail6e�to-raresr:` �1Y11e11` �"""�Founclation Property Line l , 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, stat)laws, and rules and regulations of the San Joaquin Local Health District.. G I lHome owner or licensed agent's signature certifies the fallowing- "I cerd!ylhat in the performance of the work for which this permit is issued�I shAll not ! employ any person in such manner as t6Ybecorne subject to workman'slcompensatiod laws of California." Contractor's hiring or sub-contracting signature certifies the following:_1 ceN6—thatirl��ttte �rf31F1rienca of'the work-for-"iich•,tfiis per I it is issued,I shall employ persons subject to workman's pompensa- tion laws of Ca)'ifornia." The applicant I r require ins ctions. Complete drawing on rev rse de. Date: Signed �• Title: i FOR DEPART ENT USE ONLY j } [ Date--�� i Application Accepted by � Area O Pit or Grout InI pection by Date 47/kFinal Inspection by Dated Additional Comments: r _ p-5tk 466-61$1`_--❑-Lodi`-�3�-`382'tT-^--fl-Marlteca-- _ =7104---^---L Tracy-835°6385 ---•. ---k--.__...,_.... ._ iApplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2D09, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED �I CA3H 'fY RECEl 'ED1BY DATE PERMIT`N07_ INFO h + EH 13-24(REV.10183E EH 14-26 J