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h -" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA PAYMENT ` Telephone (209) 466-6781 R E G E I V E O PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' lolr--tC ry .. i`J0� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w��llererri� r �� I rrl�cNY a ron is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules ar,131BW11 1iRbfl(_hb`San Joaquin Local Health District. Job Address 67 —7 Ile City r' Lot Size PM Owner Name �C7 V �ff Phone AAddress J_ CSGGe.rOw t�S 4 S�7a ��Jl��{ ' Contractor 6 ` V_U) AAddress�C7 syr �'{' LiceQe tQo. Phone 93 TYPE OF WELL/PUMP: NEW WELL.A` WELL REPLACEMENT ❑ DESTRUCTION ❑ l�q PUMP INSTALLATION ❑�'"' SYSTEM REPAIR [71 OTHER IX �� mW DISTANCE TO NEAREST: SEPTIC TANK �ZY6n SEWER LINES DISPOSAL FLt3. —HE PROP. LINE FOUNDATION 10430 ' AGRICULTURE WELL:!FOO OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private 'Gravel Pack Dia. of Well Casing Type of Casing Specifications i r 11 Public I I Other F1 Delta Depth of Grout Seat Typ of Grout_� a a(,4 1 I I irrigation --Approx. Depth I I Eastern Surface Seal Installed by rt S Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction © Well Diameter Sealing Material (top 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is r _ vailabla within 200 feet.) - Installation will serve: 'Residence_ Commercial— Other p Number of living units: Number of bedrooms ,//{�S/ Character of sail 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/4 No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L 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 1 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 applicant.mu t call f r aft required insppcfipns. omplete drawing on reverse side. J Signed X t �rJ/ Title: }� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by �N�l� pate �� Q Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATEPERjIN30EH13-24(REV.ri n s1 5EH 14-28 �S „'+ ^ � € L! �9