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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 4 0cp,1-YE-gJ 1,gISlO1 1J1N l s�4_F-6 tt Application is hereby made to the San Joaquin Local Health District for a permit to construcl9ft?4Q4�he:vl+drdc'+erei de�r� his application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well y,0 the4t"i s 1`94;9Yions of the San Joaquin Local Health District. {` Job Address 7 Q T - City G4c."Vol-Lot Size PM Owner's Nam �d 4�6 Address ` - �� Phone Contractor&42t-- "�71lz"Address �f � License Nw S 3 �Phonea TYPE OF WELL/PUMP: NEW WELD' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIOP SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TI S Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing �T — Specifications IV--G�?" ❑ public OtherMd&,(!Wr❑ Delta Depth of Grout Seal lJ--6� Type of Grout I I Irrigation _____Approx. Depth l II Eastern S ,f Seal Installed by p Repair Work Done L-1Typeof Pumpyh H.P. r State Work Done Well Destruction ❑ Well Diameter Sealing M erial (top 501 ( ) Depth Filler Material (Below 50') TYPE. OF SEPTIC WORK: NEW INSTALLATION Ll REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.1 ni 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number SUMPS El 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 Di?atrict. 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 taws of California." Contractor's hiring or sub nature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall emt)IAy p r�tdsXl�ba=, an s compensa- tion laws of California." SAN �OAQ ` HEAI T' y D! r V IRON I'.AIUN"l The applicant mu call f 1 r ire inspections. Complete drawing on re arse de. Ir ��xL V�, N��l,TL Q Signed X Title: JIFj Date: IV r ! FOR DEPAR MENT U E ONLY Application Accepted by w�'— "� _ Date 3 Area Pit or Grout Inspection by � Date / Final Inspection by by Date Additional Comments: ,f':: ��Y�®L�� I' �u `ti'' fe? ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-&385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AM UNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO '7 J�CASH +.EH13-241REV.1i145l ��J - �o Eli 14-2e