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' = APPLICATION FOR1'PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601'E. HAZELTON AVE., STOCKTON, CA ; Telephone (205) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. L Job Address �`'`� Q! ` PfC City Lot Size PM Owner's Name 4/3 ddress 7296 one 0 9 1 Contractor Address J`~.ZJ`^ � � - License No.��/._ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK J'rO SEWER LINES DISPOSAL FLD. C'0 ` PROP. LINE FOUNDATION_ AGRICULTURE WELL. OTHER WELL. PITS/SUMPS —,- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 00 ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private X Gravel Pack ❑ Tracy Type of Casing_ f*"'PYZ!, Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Gro ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diamet Sealing Material (top 501 Depth 1'77 Filler Material (Below 509 v TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i; Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 171 Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ 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 y 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 follow' g:"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 Calif rnia." The appli tntst call for-0 req 'r spections. Co plate drawing on rev e. Signed Title: Date: �! OR DEPARTMENT 4E NLY Application Accepted by Date Area d� I Pit or Grout Inspection ate 2=L_1_VFinal Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFO + EH 13.24IREY.x/65) -7Q R` �� I—M3 �/� `-'7 EH 14-26