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a + APPLICATION„FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ! 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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. +. Job Address 6 6c�� 44��4�� r n City Lot Size PM • �V1. tCe-CCf& 1�� Owner's Name Address Phone Contractor. ddress �� icense No.�� Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TQ NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 ? FOUNDATION AGRICULTURE WELL O,THEFt WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom •—p-Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public I ❑ Other C .1Jelta Depth of Grout Seal Type of Graut __ I I Irrigation --Approx. Depth-4-1-Eastern Surface Seal Installed by- V .� �,.. - Repair Work Done ❑ Type of Pump H.P. State Work pone Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth I Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/A-DDITION DESTRUCTION ( 1 Wo septic system,permitted if public sewer is yavailable within 200 feet.) Installation wily"serve: Residence_Commercial�-.�.ROther 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 PKG. TREATMENT PLT. ❑ f Method of Disposal " Distance ton crest: Well Foundation Property Line i _ F LEACHING LINE No. & LeN!,h of lines Total length/size FILTER BED ❑ Distance to.nearest: WeIN Foundation' Property p rty Lme I �1�0— ao -e T`A ��i 5T rub• f a SEEPAGE PITS 11 Depth ' Size Number f �. SUMPS L-) Distance to nearest: Well 'Foundation Property Line f DISPOSAL PONDS ❑ s 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 Diltrict. 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 bec me subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the 'To certifies of the work for which this permit is issued, I shalkemploy'.persons subject to workman's compensa- tion laws of California." i a{ The applica II for quired i ctions. Complete drawing on reverse sifda. q i Signed X U� Title: C"G L, /'` I R! . Date: FOR DEPARTMENT USE ONLY Application Accepted by Data 11` _U 1 Area ( Pit or Grout Inspection by Date Final Inspection b Date % Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE � AMOU�REMITTED, CK HRECEIVED BY DATE PERMIT'NO. EH 13-24(REV.iin5110 fl + °sem ♦ _ �j EH 1l-29 I O +v-