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�-� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT ✓ �� `�� t [r f 1601 E. HAZE T ON AVE., STOCKTON, CA y J\,l_e Telephone {209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED f -� I•Z( 'its.- A-��i.J;�.�2� ' (Complete in Triplicate) A plication 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 L&cal Health District. J1b AddressCity_ Lot Size PM olner's Name Address - Phone Clntractor Address License No.� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLA MENT ❑ DESTRUCTION ❑ di 4 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ QISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES DISPOSAL FLD. PROP. LINE- \ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED^USAE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TJQ S J ll LSD Industrial pen Bottom - ❑ Manteca Dia. of Well Excavation 015. of Well Casing Domestic/Private t❑ Gravel Pack ❑ Tracy , Type of Casing Specifications �F ~ k 1, Pub]' l ❑ Other 171Delta Depth of Grout Seat Type of&out .I Ih rrigation ; y _Approx. Depth I l Eastern~ Surface Seal Installed by J f Repair Work Donee ❑ Type of Pump H.P, �� State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50'1 SII _ i ! Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet.) nstallation-Will cerve:.;,Residence,� Commercials Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SSI PTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal = CIS r•: i I XII I , Distance to nearest: Well Foundation Property Line "y '�� l.r y LACHING LINE FI ' ❑ No. & Length of lines Total length/size ! I� t LTER SED 4 ❑ Distance to nearest: Well Foundation Property Line IIF. SEEPAGE PiTt I i Depth Size Number • SUMPS , ❑ Distance to nearest: Well Foundation Property Line RISPOSAL PONDS ❑ e 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. the work I-tome owner r licensed agent's signature certifies the following: "I certify that in the performance of .for which this permit it-issued,I shall not employ any pea son in such manner as to become subject to workman's compensation laws of�Caiifornia." Contractor's hiring or sub-contracting signature 1 certifies the fol'owing: "I certify that in a performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C lifornia." 7k1e applicant all for II re din ctions. Complete drawing on arse s' e. o� Signed Signed X Title: Date:- � FOR DEPARTMENT USE ONLY ' 4 Application Accepted by Date 3 1� Z�- Area ® L Pit or Gtoyt In by �i ate Final Inspection by 1 l d""t9 / Date ' Z pl r Additional Comments: .a i -'�'-Stk�466'6�rBibdi�-s65'3621'��C`�-Mantec&�823=7104�"'`'0'T�cy 835=6385' �V Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , ` INF�Q AMOUNT DUE AM NT REMITTED CK RECEIVED BY DATE PERMITNO. ITC CASH W +.EH 13-24 1REV.i i H 51 �1, r,r7-a • /.O ,�C��n^^srl / f EH 14�2e r�d r,3