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APPLICATION'FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)1466-6781 { 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 i Local Health District. ["3 1 cry PM,-ca J �, .�if City J G-lel-� Lot Sita j Job Address /vf j �] p /�/ p WAY r / / IjJ4 �s �� Address J I7, A AHC I WAY Phone" Owner's Name a , Contractor ` .Acense No. Phone r TYPE OF WELL/ .UMP; _ NEW WELL x WELL'R_EPL_ACEMENT _❑ DESTRUCTION ❑ ~ u PUMP INSTALLATION 11 , SYSTEM REPAIR ❑ OTHER ❑ r �Jti7 DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES ,� _ DISPOSAL FLD. tIs PROP. LINE ?+�- t FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM.Af3EA CONSTRUCTION SPECIFICATION ❑ IndustrialOpen Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing 7omesticIPrivate I LJ Gravel Pack ❑ Tracy Type of Casing -�-� _ Specifications 1O,�t t1 f I Public " Cl Other n Delta Depth of Grout Seal Type of Grout `. _ A rox. Depth E I Eastern Surface Seal Installed by 7'� - I I Irrigation _ PP p Repair Work Done ❑ Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 11 Depth Filler Material I,Below 50'1 T E OF SEPTIC WORK: NEW INSTALLATION l I REPAIR IADDITION.I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation w e: ResidenceCommercial_ Other ; . .` i Number of living units: Number of bedroom_ s .., Character of soil to a-depth of 3 feet: �'�' *"Water table depth Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg + PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: ,Well mFou a Property Line LEACHING LINE ❑ No: &-Length of-lines,I Total le size a',;L -_. ! 4 0'- OM1.'1, - J FILTER BED, ❑Y Dist8nce'to nearest: / Well Foundation Property SEEPAGE PITS I ) Depth Size e Number SUMPS C-1 Distarica 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. Horne 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 i employ any person in such manner.as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature k 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." °e The applicant must c it for all required ins ctio plate drawing on reverse side. Signed X tie: Data:� FOR DEPARTMENT USE ONLY DC7 k Application Accepted by Date (�//Jj�Area yPit�r6ut Inspection by r Date` Final Inspection b �l�p� Date Y — ---�–g � Additional Comments: ` 4' 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 FEED DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH t EH 13-24 IREV.t/n 51 [97-�.+r EH 14-26