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StAPPLICATION FOR PERMIT D - - SAN JOAQUIN LOCAL HEALTH DISTRICT Q Vy 1(p �g8� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 1. L� ` PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED �{()s Er1V RM��SE (Complete in Triplicate) FF,R Application�iEhereby 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 witli 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. Job Address-10-747/7 (ii/ `lam e— Gity Lot Size�� PM l Owner's Name � ��Cy'"� � Address ziy. I d/l /�G( Phone Contractor Address&YY License No,265�7dl Phone sfi If TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM T C7 DESTRUCTION ❑ \ PUMP INSTALLATION ❑ SYSTEM REPAIR .� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _—_AGRICULTURE.:.WELD-_—WELL - OTHER-WELL - PITS/SUMPS= ` xw. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial '❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other } C 1 Delta Depth of Grout Seal Type of Grout I Irrigation _..Approxi Depth - I ! Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. � _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth - Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted it public sewer is ` f 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 i Capacity I No. Compartments PKG, TREATMENT PLT. 01. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED E) Distance to,nearest: Well Foundation Property Line F SEEPAGE PITS l I Depth r Size Number ` SUMPS Ll Distance to nearest: Well Foundation . Property Line 1AS_P Or9_As R0-•NDi_ f-❑ aw. � - '.`: w.aN �,..^ -�o.r'r' �.� �r;.�,'..-r ,...ce,.-;e�„rA-•.:�-.. -p-�r ; 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 t ollowing: 1 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- rSine s of anfornia." �- can st c r all re vire s ions. Complete rawing on reverse side. _ bate: r Poll O PARTME T USE ONLY Application Accepted by Data_ �~� ! Area Pit or Grout Inspection by rr-- Date Final Inspection by Date&2��/— Additional Comments: i LJ 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 t FEE f INFO AMOUNT 'DUE '� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 13.24(REV.i K5) a �}-✓ n�p t[,/_`ICJ�� EH 14-211 SCJ O� J - I