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1 I p.i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E�HA;ZELTdN LIVE,, STOCKTON, CA s Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED--). �� f . . (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct an li the work heteln scribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/p ' and toa-Ruies�anc �iegulatior�siof the San Joaquin 4 [-�- C T1 Local Health District. Job Address �'�� Y ¢ PM Owner's Name P re_ e b c. Address r12 IMrA M Me'er Phone ff Y104 Q 7 Contractor � L Address J� 1 License No.Lb!373 Phone L7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑i DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLQ. PROP. LINE -.i' F0U.INDA.T.161 � AGRICULTURE WELL OTH'E'R/ WELL PITS/SUMPS INTENDED USE TYPE OFE WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ ❑ industrial ❑ Open'86ftorri ` t "Manteca Dia. of Well Excavation �', Dia. of Well Casing ❑ Domestic/Private © Gravel 'Pack G,- ❑ Tracy Type of Casing �`�'� Specifications fl Public f 3Other 11 Delta Depth of Grout Seal � � Type of Grout I I Irrigation -Approx. Depth I Pastern Surface Seal Installed by Repair Work Done f.�"1TY�e of Pump 5CA— - H.P. / State Work Done� tm� WeltDestruction 3:-0, Well Diameter Sealing Material atop 591 1. Depth Filler Material (Below 50') � TYPE OF SEPTIC WORK: `NEW INSTALLATION l.) REPAIR/ADDITION l I DESTRUCTION I I iNo septic system permitted if public sewer is tavailablelwithin 200 feet-) Installation will serve: Residend Trr-1eicial— Other li 1 Number of living units: Number�of!bedrooms _ Character of soil to a depth of 3 feet: -s Watertable depth SEPTIC TANK ❑ Type/Mfg `-=a apacify ! No. C�partments PKG. TREATMENT PLT. ❑ l 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 I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line I DISPOSAL PONOS ❑ 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 f rules and regulations of the San Joaquin Local Health District. Home owner or li 's signature certifies the collo : "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe on in such man er as to becom su "ect kmarl' ompensation laws of California." Contractor's hiring or sub-contracting signature certifies the Ilowing: "1 certify t tin th c f t work f r which this permit is issued, I shall employ persons subject to workman's compensa- tion laws California." r The app!' ant mus all Ito require n plate dr ng on re r 1 Signed Title: Date: FOR I TMENT USE ONLY Application Accepted by Date WArea Pit or Grout Inspection by Date Final Inspection by - _ 4311--aw Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT' 0. +.Eli 1 -21(REV.1/n 51 3S� EH 114-28 ! �O