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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA T. Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED , (Complete in Triplicate) Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is F 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. 41 Job Address I t!'/ �. #35 City �'b dist Size PM l _ (q� 4 Owner's Name Ir" + C t` Address N ��1 Q tv Phone 7 Contra or >� zi }' S�Address 6 I C kTi � ense No. �ZC3 Phone d �f 3 7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR El OTHER O DISTANCE TO NEAREST: SEPTIC TANK L> SEWER LINES 14-b DISPOSAL FLD. PROP. LINE � �17 FOUNDATION I AGRICULTURE WELL OTHER WELL 4 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS jf ❑ Industrial en Bottom ❑ Manteca Dia. of Well Excavat^ion Dia. of Well Casing "omestic/Private ❑ Gravel Pack E] Tracy Type of Casing__ 6Ipsx ft r (`` Specifications i'1 �— Public f_1 Other ❑ Delta Depth of Grout Seal S Type of Grout i Irrigation —..Approx. Depth ( 1 Eastern Surface Seal Installed by�_ ?�, k 5 :J a -- ;Repair Work Done --❑ Type of Pump; v b� H.P. State Work Done Well Destruction ❑ WellDiameterSealing Materia! {top 50'I i Depth I Filter Material Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REP..AIR/ADDITION i I DESTRUCTION ( I (No septic system permitted if public sewer is 1 t 144 1 available within 200 feet.) Installation will serve: Residence_ 'Commercial Oiher Number of living units: Number of bedrooms�f Character of soil to a depth of 3 foes: "�� 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 ❑ No. & Length of lines - Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line t SEEPAGE PITS f I Depth Size , Number SUMPS C1 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 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, 1 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 shalt employ persons subject to workman's compensa- tion taws of California." [ The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: C Date: f i OR ARTMENT USE ONLY Application Ac pte by Date Area ro Pit or rout Inspection by Date Final Inspection by Dat - `�/— Additional Comments: � / 19d ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Man ca' 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 E;/7 PERMiT'ND. INFO H + EH 13-24 IrtEV.1/H 51 J/7,[ , /�` / �n� /EH t4-26 / f/C] / b t.J,a[ j _qq�b