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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEILTON AVE., STOCKTON, CA + Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rr (Complete in Triplicate) R,� _ CHle, (toy 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 les and Re ulations of the San Joaquin Local Health District. & f`_ �+✓S " L�� p- 7 � i��- C� Job Address City tot Size �p t Owner's Name � a ,� �Qnd�a �')'i_�'Addres�s _� n 2��[F U d�2. __ Phone .3 f n - Contractor's Name License No. q Q 3 T?_- Phone RIO _a �., TYPE OF WELL/PUMP: NEW VAtL 9It�- s "WELL REPLACEMENT 171 DESTRUCTION ❑ MP PUINSTALLATION' R+ YS STEM REPAIR�❑yOTHER ❑ E, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD-34D Q _ PROP. LINE FOUNDATION /S D AGRICULTURE WELL OTHER WELL nOR PITS/SLIMPS J r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Weil Casing X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S71�cel' i r Specifications } ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type off Grout'7K Sand �Ot)V' f � � x" 111 Irrigation Approx..Depth LJ Eastern Surface Seal Installed by, I H f+'L Repair Work Done ❑ Type of Pump _ 4 H.P. - State Work Done i' Well Destruction ❑ Well Diameter Sealing Material"(top 501 Depth Filler Material (Below 50') J 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 1' "Character of'soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J� PKG. TREATMENT PLT. ❑ "+- WMethod of Disposal U Distance to nearest: CNeII�Foundation Property Line E i wA LEACHING LINE ❑ No. & Length of-lines Total length/size ' FILTER BED ❑ " Distance to nearest: }€Well""Oww" "�"FoundationProperty Line r SEEPAGE PITS ❑ Depth A. es Size Number SUMPS El Distance to nearest: Well Foundation Property Line #DISPOSAL PONDS ❑ JF I .. 11 herebyleertify 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. 1, k Home owner or licerind 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."Contractors 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."..�."O*",.r�.. --- —— " ,,..a ��.-�-'-"""'" _ e The applicant must call for all required inspections. Complete drawing on reverse side, f Signed X rn fX% 1`i Lt�1/1AAJQ-,X—,-._ Title: s Date: -3& FOR DEP TMENT USE ONLY / ��J Application Accepted by Date / ge Area y 5-r I Pit or rout t"ction by Date .1 Inspection by Date,`7 t :Additional Comments: I ❑ Stk 468-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all pie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO CASH �� a �� + EH 13-24[REV.10!831 4!g►l EH 1428 / �. �•l