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lye- 2q� 110 [3 : APPLICATION FOR PERMIT SAN JOAQUIN LOCALMEALTH DISTRICT 1601 E. HAZELTON AVE.,+STOCKTON, CA Telephone (209) 466-6781 i. q PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' (Complete in Triplicate) illrmit to construct and/or install the work herein described.;This application is Application is hereby made to the San Joaquin Local Health District for a pe made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the R41es and Regulations of the San Joaquin Local Health District. '� J V ` - f� �' Ci # LotFSize Job Address " �� d ty ,t• 1 za} Phone Owner's Name 1 B iS t �1 .Address a - - Lic en No,- � � Phone - Contractor L - �.�—Address " NEW WELL ❑ WELL L1' REPLACEMENT DESTRUCTION ❑ ' `'" TYPE OF WELL/PUMP: t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ {Ls ?0 ER ❑# �r` "�s �, DISTANCE TO NEAREST SEPiTIC"TANK SEWER LINES DISPOSAL FLD:_ PROP..-LINE �• A FOUNDATION AGRICULTURE WELL t OTHER WELL\ PITS/SUMPS �i'ti � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing £. (� ' fr s:. r° Type of Casing Specifications ❑ Domestic/Private O Gravel Pack. �❑ Tracy YP g s ❑ Public ❑ Other 4 O Delta Depth of Grorlt Seal Type of Grout 171 Irrigation pprox.Depth i` ❑ Eastern" Surface Seal Installed by State Work Done Repair Work Dane* ❑ Type.�of Pumps - H•P. 11_�Well Destruction ❑ Welli�Dia r Sealing Material (top 50') y! Depth ' Filler Material (Below 50'1 s 1 TYPE OF SEPTIC WORK: NEW INSTALLATIONOF, REPAIR/ADDITION ❑ DESTRUCTION El-.:(No septic system permitted if public sewer is I' I " 'available within 200 feet.) S, 1 Installation will serve:' Residence Commercial_ Other �a Number of living units: ��' Number of dr s �- .- �f--* Water table depth— Character epth r Character of soil to a:depth of 3 feet: I SEPTIC TANK ❑ T e/Mf Capacity No.°Compartments t" yP g K PKG. TREATENT;.PLT. ❑ Method of Disposal M r Distance to nearest:., Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines �41T al-length/-size FILTER BED ❑ Distance to near Well r� Foundation 0 � Property Linea BEEPfirGl�tS ❑ Depth : Size Number S ❑ Distance to nearest: Well Foundation Property Line t i 1 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 I rules and regulations of the Sd'n-d ao quin Local`Healfh,,District. cod' } - ' �^------ t� Home owner or licensed agent's signature,`certifies the following: "I certify that��the-performance-of_the work for which this permit is issued, I shall not employ any person in such manner-gto become subject to workman's compensation ompention IA` sof dalifornia.' Con rtrt actor's hiring or sub contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,Tshall-employ persons subject to workman's compensa- tion'laws of Californie4' Theiapplicant must call..for equir d inspections. Complete drawing on reverse side. X a ,- t Date: Signed Title- x FOR DEPARTMENT USE ONLY .,e licatian I � A �' (�` r �-^ .Date Area PP Accepted by i �t Date Final�� Final lnspeacin by Date Pit or Grout Inspection by - ; Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621/ ❑ Manteca ,823-7104 t ,❑ Tracy 835-6385 Applicant- Return aH copies io: Environmental Health Permit/Services:1601 E'"Hazelton Ave., P.O. Box 2009, Stk.,.CA 95201 4 V 4 t� �a. •• y.'t , INFO AMOUNT DUE AMOUNT REMITTED DASH RECEIVED 9Y DATE >,* PERMIT NO. F k.r = ff c ' +EH 13-24 Mev.1/8 51 { �� _-" k _ r OS EH 14-26 I r i �