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t r APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT r 1601 E. HAZE T ONAVE., STOCKTON, CA Telephone (209) 466-6781 `�T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) T 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. r sewage or No. 1862 for well/pump and the Rules and Regulations of the }amu Local Health District. * i'' FC 1. [GfY/!/ Job Address t''. r City r4:, ''Lot Size PM " Aw len-ft":��cJP I-�iYl. ( . ' Owner's Name x'17l !L f4 [ Address S40 /f1QrlI"CJ A Phone aiw Contractor D Address �5 License No. Phone k TYPE OF WELL/PUMP: 6 NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ . SYSTEM"REPAIFt.0 OTHER..❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE FOUNDATION - AGRICULTURE'WELL---�OTHER-WEL'L _ " " 'PITS7SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom`+ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑q.Gravel Pack ClTracy Type of Casing Specifications ❑ Public ❑"Other,) ❑ Delta Depth of Grout Seal Type of Grout �:.1-- ❑ Irrigation __�Approx. Depth EJ Eastern Surface Seal Installed by Repair Work Done El 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 ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ two septic system permitted if.public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial=NOther' Number of living units Number of bedrooms Character of soil to depthof.3 feet:, -- Water table depth SEPTIC TANK El _;Type/Mfg �ti; Capacity No. Compartments i PKG. TREATMENT PLT'❑ Method of Disposal Distance to nearest: Well Foundation Property Line F LEACHING LINE ❑ No. & Length of lines Total length/size FiLTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i ❑ Depth Size Number SUMPS ,❑ 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, 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 must call fo re I inspections. Complete drawing on revers -side. 4 Signed Title: Date: FOR DEPARTM NT USE ONLY `' Application Accepted by Date -71,71114—i? 1l Area � 2 Pito Grout inspection byDate Final Inspection by Date � Addi' nal Comments:- tk 466 6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 { Apph t- Return all copies'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE fINFO AMOUNT DUE ' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`N0. ! , EH1a-2a(1iEV.t/BS] v.e v� t� , O ko4V r r%1/ S ?17 EH 1426 _ � , i i