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,• APPLICATION FOR.PERMITy a � SIAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA p II Telephone (209) 466-6781 O PERMIT EXPIRES 1'YEAR FROM DATE ISSUED P (Complete in Triplicate) i Application is hereby madeto 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 Di/try t,,,� ^� � ' .� �` A-V N \k fly—14v"`-� I Job Address N 44'�((ZZ55 N F I G6eZ -e.-r/Z6 SM� City�rc�.t TOQ.' Lot Size PM r Owner's Name SW-a Q? AAQ • � Address ��/�Z?�1uzr>��' 57eCE1 Phone !I I Contractor SE-=( Atldress /C/$QT. h), r,I1,12x'7aTSTAA4Efficense No. Phone 6 j TYPE OF WELL/;PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ jl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC'TANK " N` ` SEWER LINES DISPOSAL FLD. PROP. LINE l p FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial q ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation Dia. of Well Casing ❑'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing; Specifications F1 Public ❑ Other ❑ Delta Depth`of'Grout Seal- Type of Grout 11 Irrigation Approx. Depth 1 1.Eastern Surface SedInstalled by ' Repair Work Done L-1 Type-of-Pump.. j - H.P. `State Work Done— Well Destruction1 ❑ Well Diameter �� Sealing Material (top 501 Depth Filler.Material (Below=501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 -REPAIR/ADDITION t l DESTRUCTION I (No septic system permitted if public sewer is t ;{ I 'available within 200 feet.) \v\ p Installation will serve: Residence Commercial— Other _ I Number of living units: Number of bedrooms ! 1: F .. ` Chara_cter of soil to a depth of 3 feet: �t Water table depth SEPTIC TANK + ❑ Type/Mfg Capacity - No. Compartments / ! PKG. TREATMENT PLT. ❑ P Method of Disposal N Distance to nearest: Well Foundation Property Line LEACHING LINE "0— 'No. & Length of lines ' Total length/size FILTER BED Il ❑ Distance to nearest: Well Foundation 1 Property Line SEEPAGE PITS , t I Depth �G Size _ Number f Ru'• - ,des; SUMPS Gl ii ,Distance to neatest: , Well Foundation Property Line DISPOSAL PONDS ❑t thereby 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 for all require inspe ti I�s.-Complete drawing on reverse side. 1 ._. u / Signed X i 9./2f` r Title: Date: j j cp FOR DEPARTMENT USE ONLY Application Accepted by Date Area 1 Pit or Grout Ins ction by Date Final Inspection by Date Additional Comments: _- L 7" f,5-K, , 7L— //, /> El Stk '466-6781 ❑ Lodi .369-3621 1�0 Manteca 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 ' INFO FEE AMOUNT DUE MOUNT REMITTED (CASH RECEIVED BY DATE P-ERMITCf'_N .YOJ. + EH 3-24(REV.ii n s) 12,-467 EH 14-26 ! I 10, t