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APPLICATION FOR PERMIT s SAN JOAO,UIN--LOCA-- HEALTH DISTRICT p%N 1601'E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED ftt Y T Mrt.. {, (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. .f , , f Job Address �� '�. ��t-t 4 ` ' D"Z)Ir,CL-An City DG� `� Lot Size PM Owner's Name�ln�t Lncr kt _r L pule Address �l Ncw Je- S�a�k�� Phone 9� Contractor—1-W Kl n l� S- �ks-,Address License No. Phone!14, 3�6�� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT El DESTRUCTION ❑ s PUMP INSTALLATION SYSTEM REPAIR El OTHER ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ) FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation�`'� Dia. of Well Casing 2 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing !V<. Specifications ElPublic ❑ Other s ❑ Delta Depth of Grout Seal y0 `r Type of Grout } ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by rh 't'(' a.r dQBr Repair Work Done ❑ Type of Pump H.P. -��A- — State Work Done_ Well Destruction 3K Well Diameter `} Sealing Material (top 501 `^ - _ Depth ° - F -- Filler Material (Below 501 TYPE OF SEPTIC iORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is rn available within 200 feet.) Installation will serve: Residence Commercial, Other �l 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. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line .� F LEACHING LINE ❑ No. & Length of lines i Total length/size V FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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.ordin�ces, 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."Contractors 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 applicant must call r all r quired inspections. Complete drawing on reverse side. pyY7 : :Sa.t"� nDate: Signed Title FOR DEPARTMENT USE ONLY rJ Application Accepted by Date"—/. -�" `� Area ,— � 0/"�6"� Final Inspection b Da.-- k Pit or Grout inspection by j Date Pe y ; _ a € dt✓'P_C W ry S 2.ps�e �yy,tip i Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT''NO. + EH 13-244REV.1 85) 3s. 47 EH 14-28