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,A4�a-'-k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. J ,Y Y/g Y Job Address J 1 � N. Alpn- City 5 �� Lot Size 4 CA A-> PM Owner's Name ,/� ,/�, ��,,.�n�,��¢ Address / Phone ,.�� `--� Contractor M-f r r AI ''4/7%ddress Se.�Q i License No. �r� P ne 'F �3T TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUC N PUMP INSTALLATION SYSTEM REPAIR ❑ HER DISTANCE TO NEAREST: SEPTIC TANK 2-049 _ SEWER LINES 1 501 DISPOSAL FLD. ��,,��II PROP. LINE FOUNDATION �QI AGRICULTURE WELL ' OTHER WELL. PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j LlIndustrial ElOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing /? *Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1 Other fl Delta Depth of Grout Seal Q 1 Type of Grout — I I Irrigation —.-Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump s b," H.P. State Work Done Well Destruction ❑ Well Diameter o/ Sealing Material (top 50') Depth r Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION"I`l REPAIR/ADDITION I 1 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 Capacity No. Compartments V. PKG. TREATMENT PLT.`:❑ 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 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, stat ws, 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 Calif- The applicant m t call for al_I�gr4red in ctio�mple drawing on reverse side. G� I Signed X �jJ_�/ Title: �)♦°- Date: (J F NT USE ONLY Q G� Application Accepted by . l Date F ' ` l Area Pit or Grout Inspection by Date��/ Final Inspection byGf Date x/31-2 Additional Comments: - ,e- ❑ Stk 466-6781 ❑ Lodi 369-3621 W7Manteca 823-7104 ❑ Tracy 835-6385 lD 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., tA 95201 IN�FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT�NO. CASH +.EH 14-24 IREV.1/x 51 Z EH 14-ze c fTp r C7� 7 -L_