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4 � r APPLICATION FOR PERMIT ,F SAN JOAQUIN FOCAL HEALTH DISTRICT t 1601 E. HAZE,-i QN AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) y 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, I Job Address ✓ d C P �/' City E'!� Lot Size ! PM N c7 /4 / Owner's Name .. . tr CQ, LI S' Address A�~ �� Z,47Ttr,/ '! Phone Contractor Address V � � License No- Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ I r PUMP INSTALLATION SYSTEM REPAIR ❑ -OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANI> SEWER LINES> �� QISPOSAL FL�� PROP. LINE Iu�f i FOUNDATION,>./6-0 AGRICULTUREWELL 5V OTHER WELL X PITS/SUMP� t'LJf _ r INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS.. _ II » ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation xDia.'of Well Casing"� t LJ Domestic/Private Gravel Pack ❑ Tracy Type of Casing s 11tJi/�/'- Specifications Public Ll Other 171 Delta Depth of Grout Seal _ /O` f Type of Grout I y I I Irrigation —,-Approx. Depth l 1 Eastern Surface Seal Installed by; Gs��Jf!'�<G�17 6 Repair Work Done ❑ Type of Pumps_ WA&X&5n5'z�WP(V ''P� State Work Done Well Destruction ❑ Well Diameter e:p ar Sealing Material (top 501 Depth S_6 Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth 1s SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �M PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �l � LEACHING LINE L1 No. & Length of lines Total length/size -FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth � Size _ Number. M SUMPS ❑ 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 District. Home owner or licensed ' a ents signature certifies the following: ._.' g g g: "1 certify that in the performance of the work for which this p—ermit Is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signatures certifies the following: "1 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.'—--- r The applicant nrAt call far all quir din ctions. Complete drawing on reverse side. / Signed X a /Title: / V fiTiT Gr�1 y/�t/L Dais: _-� FOR DEPARTMENT USE ONLY I �' Application Accepted by Date / Area Pit or Grout Inspection by ate Final Inspection bv`` Iv 1 V�^� I�Date �yZ l - Sv I Additional Comments: ' °L GL�d j 71, / ❑ Stk 466-6781 ❑ Lodi 369-6621 ❑ Manteca 823-7104 `@ ❑ Tracy 835-6385 IM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r hJ ,�y fj FEE F INFO Mt`OUNT�DUE AMOUNT REMITTED GASH RECEIVED BY DATE O�NO. +.EH 13-24 IREV.CH 14 2Be � � r