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it I� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED q (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. �. it 4tr Job Address •a City Size / PM VO " '` Owner's NameC!/cY�tiiA � Address Phone ��G")'�'1`-�� 5 ` �yw e Cry- Contracio � ddress �/ /fes / License No.! 91 phone_ TYPE OF WELL/PUMP: I� ! NEW WELL ❑ r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 11 ' ? SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION . 4AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL'S PROBLEM AREA CONSTRUCTION SPECIFICATIONS A i 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation '" Dia. of Well Casing 1-1 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing w Specifications a Fl Public ❑ Other Cl Delta Depth of Grout Seal a Type'of Grout _ I I Irrigation --.Approx. Depth t I Eastern Sbdace Seal Installed by Repair-Work Done ❑ Type of Pump H,P.. " ' TMState Work Done_ Well Destruction ❑R x.Weil Diameter` (Sealing Material (top 501 Depth - •• �._ Filler Material (Below 501 f k TYPE OF SEPTIC WORK: NEW INSTALLATION I RE-PAIR/ADDITION E I 'DESTRUCTION I I (No septic system permitted it public sewer is :.i �: � k aver ble wit 200 feet. t Installation will serve: Residence�; Commercial:-- Other r Number of living units: I� Number of bedrooms t Character of sail to a depth'of 3'feet: Z.= —' ° of # I Water table depth € SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C7 f Method of Di' sp 3 - Distance to riearest; ::: . Well --u--S�-- Foundation Property Line AV AL t Air I LEACHING LINE ❑ No. & Length of linesTotal length/size — F%r 0 Property p FILTER BED ❑ Distance to nearest: Well Foundation Line _ II SEEPAGE PETS i I Depth Size — _ Number t ' ' i SUMPS C1 Distance to nearest: Well Foundation Ici`, Property Line I 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 r rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agents 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." IN i The applicant c_st call for talirquired inpections. Compete drawing on reverse side. Y t—Title: �C.t/Y1_A e'C . Date: Signed X � t II DEPARTMENT USE ONLY A lication Acce ted b __ Date _``� + Area A) ! PP P y Pit or Grout Inspectionby I� ate Final Inspection by Vel4�12K4',I&I Date Additional Comments: ❑ Stk 466-6761 a Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 E Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t CK FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. } +.CH 1 3'24 IREV.F wsi EH a-ze