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APPLICATION FOR PERMIT dio?s SAN JOAOUIN LOCAL HEALTH DISTRICT &�Dy I 1601 E. HAZELTON AVE., STOCKTON, CA A�` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �� `� �� ` 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. .�- r Job Address _ 957-5 City &AWLot Size C51 c PM � NySrrt. Owner's Name Address ATew —J -s Phone Contractor.�� E� /�/y S Address 1 i c e n s e No.�Phone 3,4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM SYSTEM REPAIR ❑ OTHER ❑ {y 1 DISTANCE TO NEAREST: SEPTIC TANK �; ! SEWER LINES _,---7':! DISPOSAL FLD. ✓ PROP. LINE �v FOUNDATIONr AGRICULTURE WELL ---� OTHER WELL �' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION K ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack Ll Tracy Type of Casing � Specifications /'FiPublic Ll Other 17-1Delta Depth of Grout Seal Type of Grout it/�� i I Irrigation s�, Approx. Depth 11 Eastern face Seal Installed by—_L IIM�551 ZW//_„[/SSC I Repair Work Done U Type of Pump _ C3Vr H.P, State Work Done `C Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material f8elow 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRYADDITION l I DESTRUCTION I I iNo 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 U Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation Property Line LEACHfNG LINE Cl No. & Length of lines —_ Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 11 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CJ 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 Ilk) rules and regulations of the San Joaquin Local Health Dfltrict. fl 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 s requiI ns. Complete drawing onrev/rs�side. Signed X Title: �� - Date:101, �r �� FO EPARTMENT USE ONLY Application Accepted by _ O L /O?" Date// Area - JL Pit or t rt inspection by Final Inspection by� 1-4-4 Data/'- 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.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT-DU€ AMOUNT REMITTED CASH RECEIVED BY /DATE PERMIT NO, + EH 14-21(REV.I/H s! EH U-2t3