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61 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 00 PERMIT EXPIRES TYEAR 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. Job Address City 47 Lot Size PM f Owner's Name ��-� I� R Address Phone ContractorAddress ' -rum;�12�0)icense No 9014 Phoner �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -T—PUMP,INSTALLATION _ SYSTEM REPAIR CA, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SELNER-LJNES-s,..'...— DISPOSAL FLD. PROP. LINE y .. FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Domestic/Private ❑ Gravel Pack 0-Tracy Type of Casing Specifications F] Public ❑-Other ❑ Delta Depth of Grout Seal k Type of Grout # I I Irrigation --.-Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done Type of Pump H.P 2— r_ - --State Work Done 02Qa_647� c4,4& Well Destruction LJ �.�Well Diameter Sealing___MMatt erial itop 50'1 Depth f Filler Maierial.(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I Wo septic system permitted it public sewer is available within 200 feet-1 Installation will serve: Residence_ Commercial_ Other A ,� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (A PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation. Property Line ' SEEPAGE PITS I I Depth Size _ Number ' ^ SUMPS ❑ Distance to nearest: Well Foundation Property Line ; DISPOSAL PONDS ❑ x 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 -0 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 suh-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 must c f for all required inspections. Complete drawing onreverseside. p / Signed X Title: Date:_� Date: C5 " (O —26 7 FW DEPARTMENT USE ONLY Application Accepted by Datel &Area Pit or Grout Inspection by Date Final Inspection by e— Date �O 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.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK It„CASH RECEIVED BY DATE PERMIT NO. a.EH 13-24 MEv.1/R 51 / EH 24-28 I /q. 1C'' �O