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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA I° Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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. Job Address City ALL/` Lot Size PM Owner's Name /V' &/ Address " Y Phone `50 5-192171 Contractor +� Addressf�.L�O. ' License No. o� Phone_ TYPE OF WELL/PUMP: NEW WELL t , `. WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ f ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 'Y PROP. LINE FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPSy INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / RElIndustrial ❑ Open Bottom 1-1Manteca Dia. of Well Excavation I Z! Dia. of Well Casing Cca ❑ Domestic/Private >irGravel Pack ❑ Tracy Type of Casing ��, Specifications FI Public ..17t Other ❑ Delta Depth of Grout Seal f ' Type of Grout )CInigation ?X-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump fkJe&5 H.P. : State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 v Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION l 1 REPAIR/ADDITION ( I DESTRUCTION I I (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 'C p ity No. Compartments '^ PKG. TREATMENT PLT. ❑ r Method of Disposal t Distance to nearest: Well Foundation ___,Property Line LEACHING LINE ❑ No. & Length of lines -- -Total lehgth/size- FILTER BED ❑ Distance to nearest: Well Foundation--- Propertyy Line —4— SEEPAGE PITS I I Depth Size `°`- Number �. Z 1 SUMPS L] Distance to nearest: Well Foundation Property Line 4 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 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 a req ui tions. Complete drawing on reverseside. 7 Signed X Title: ' -P� E/�� Date: � 4 i FO DEPARTMENT USE ONLY , �A� r 1 I� Application Accepted by ^n 0 =.c-_...yam �+�� Date L Area I Pit or Grout Inspection by to 7 2 ( Final Inspection by Date It Additional Comments; © Stk X466 fi781-ii--t7•-L-odi- 1_-. enter Tr cy --� ' Applicant Return all cope o: nvrronmental at te"mit/ e c s aze iiBox 2{309, Stk., A 9 01 G• 4 - x VG�� t. �ac� p.�,c wt -.�- : ,.0 - - TCd�. wit ijI,Nf'FO AMQL.FrJT pl1E' ' AMO A T REMITTE CASH"'- ""`RCEfVE�BY'�J ''7 t)J1ATE PERNtITNO: Y + EH 3-24 EH1�26fREV.rix51 Wa'v 1j 1�3.�et�'t� G~rk7 -j `'�_