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i APPLICATION�FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone (209?..466-6781 ,. 1 PERMIT EXPIRES 1 YEAR'FROM.DATE ISSUED, % (CompTete .in. T,riplicatel'! , !, r a.. ., ' °:. A, Application is hereby made to the San Joaquin Local Health District for a::permit to construct and/or install the work herein4described. 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. AL Job Address t City Lot Size !� PM Owner's Name r� � � Phone Coma,or 1 � ':Add'ress- W �:�"" License Nn. '�� ,�Phorie TYPE OF WELL/PUMP: NEW WELL ❑ k WEL•L.RI PCL7 ACEMENT. DESTRUCTION L1 ` r �"V PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTF�ER C7 »< 1 DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES: DISPOSAL FLD. PROP. LINE FOUNDATION' 1 .ti.t . AGRICULTURE WELL OTHER WELL FITS/SUMPS{ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \� ❑ Industrial{ ❑ Open Bottom ❑ Manteca w Dia- of Well Excavation Dia. of Well Casing 1i ❑ Domesti /Private C] Gravel Pack pf ❑ Tracy t Type of Casing Soecifications ❑ Public ❑'Otherti:L� 4 ❑ Delta- Depth of Grout Seal Type of Grout ❑ Irrigation1 �Approx. Depth ❑ Eastern °�� Surface Seal Installed by Repair Work Done Cl _*Ty pe,of°Pump NH.F r State Work Done Well Destruction �❑F_f e11�Diameter; Sealing Material (top 50') Depth Filler Material ( slow 50') TYPE OF SEPTIC WORK: NEW INSTALLATI N ❑ REPAIR/ADDITIONX DESTRUCTION (No septic system permitted if public sewer is G r } available within 200 feet.) Installation will serve: Residence b1� CorercialOther Number of living units: Number of bedrooms.' rt Character of1soil to a depth of 3 feet: Water table depth SEPTIC.TANK. ❑ Type/Mfg t ;> Capacity No. Compartments PKG:TREATMENT PLT. El Method of-�isposall Distance-tone est:.1 f Well Foundation( 1 Property Line I t LEACHING LINE Q No. &\Le.ngth of Ii Total l 1.ength/size t- FILTER BED C1 Distance to nearest. . Well Foundation A Property Line i v I t SEEPAGE PITS �epth : Sizer 1 f Numb r k SUMPS ❑ Distance to nearest:��Well 'Foundation 1 Property Line F ' DISPOSAL PONDS ❑ j } �. H$•�' M s ! �- I hereby certify that I have prepared this application and that-the will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Lical Health District. Home owner�or licensed agent's signature certifies tt16-f°olOo;6g: "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 toworkman`s corrlpensationlaws of Califorriia." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the petfgrmance of the work for wHich this permit is issued,I shall employ persons subject to workman's compehsa- tion laws of California." The applicant call uired ' spections. Complete drawing on reverse side. Signed X Title: Date: AOR DEPARTMENT USE ONLY y+� . . � ` e A �wu Application Accepted byA6 ') . Datrea Pit or Grout Inspection by\ Date Final Inspection b Date a✓1/' Additional Comments: 7 ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104. i ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 IFEE NFO AMOUNT DUEV AMOUNT REMITTED CK H RECEIVED BY DATE ' PERMITNO.. + EH 13-24(REV.t i e 5) l �( qt� r^/ EH 1428 tiff .. L........ - 4