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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F e 1601 E=:HAZE�:TOfV AVE, STOCKTON, CA , ` Telephone {209) 466-6781 ' PERMIT EXPIRES TYEAR FROM DATE ISSUED AUG 1 195 (Complete in Triplicate) ENVIROMENTAL4E�ALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worlr ft1RM ff�S6%Y +it 5ppI!cation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Autes and Regulations of the San Joaquin Local Health District. "] `r f Job Address LCity of Size PM Owner's Name ��Faress �_1 77 P_t/ L a VT �CPhone - Itn �- Contractor f L•t1nn Address �� 1B Contractor K License No.!6 2 3 7-3—Phone AL TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w ! .' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 1-7 Manteca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/,Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public i n Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation: �"Approx. Dept f I�astern Surface Seal Installed byi 'v _ Repair Work Done } Type of PumpG � H.P, f _ State Work Done Well Destruction [] Well Diameter Sealing Material Itop 501 �R Depth Filler Material [Below 501 TYPE OF SEPTIC WOR NEW INSTALLATION I l REPAIR/ADDITION f.l DESTRUCTION l ] {No septic system permitted if public sewer is ` available within 200 feet.) Instaffatior, will serve: Residence_ Commercial_ Other : '! Numher of living units Number of bedrooms SCharacter of soil t a:depth of 3 feet: Water table depth �f r� SEPTIC TANK P !❑ Type/.Mfg CapacityNo. Compartments I, PKG. TREATMENT PLT.j❑ Method of Disposal f � Distance to nearest: iWell - Foundation Property Line t LEACHING LINE 'r}C1 No. & Length of lines Total length/size FILTER BED #;❑ Distance to nearest: ; Well ; Foundation Property Line SEEPAGE PITS i tl I Depth ! Size y�T ",_� y } Number SUMPS Ll Ll Distance to nearest: Vl/ils Foundation Property Line DISPOSAL PONDS '❑ - - �— --�'- ------ -�•- r 1 hereby certify that I,AaJe prepared this application,•en l,thatithe.%61i will:de done in accorda�ce with San Joaquin county ordinances, state laws, and rules and re Ions o San Joaquin }focal Health Diltrict. Home o er or licensed age is signature certifies the following: "I certify that in the performance of the work for which this permit i i pe s slued, I shalt not emplo any person in such inner as to become subject t rkman's compensation laws of;California."Contractor's hiring or sub-contracting signature certifi s the following:�l ce Ify that in the pe orm ce the- ork for which this permit is issued,I shall employ persons subject to workman's compensa- tion I ws of California.'` y Thea plicant rn f SII req ed in ete drawi g on side. ?6 Signed X "— e: Date: l� L R DEEP RTMENT LISE ONLY Application Aci opted by Date Area t1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781. 0 Lodi 369-3621 ❑ Manteca 1323-7104 ❑ 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 AMOUNT REMITTED CK 9 CASH RECEIVED BY DATES PERMI-r NO. +.EH 124 IAEV.r/H 51 EH 14-4-29 ✓ �t7 Q C�IJ-VS - 1