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APPLICATION FOR PERMIT Yd `f u 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} �� JQAQUI1V Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work it rd s P�, �1`� tion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulation. laation.o'f'tiie-n Joaquin Local Health District. 3 ti/ O Z Job Address 9g.4maid 4 City Lot Size PM 4 « rJ ��C31� �W Address /L0 1 5 hon Owner's Name - Contractor's Name � - License No. A/&67!a2_6 2_6 e TYPE OF WELL/PUMP: ❑ WELL REPLACEMENT ❑ DESTRUCTIO t� UMP WSTALLATIO SYSTEM REPAIR ❑ R W I DISTANCE TO NEAREST: S T SEWER LINES. DISPOSAL FLD. PROP. LINE �(+ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 171 Gravel Pack 40 Tracy Type of Casing Specifications . ❑ Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout Q. ❑ Irrigation --4pprox. ern l Surface Seal Installed by Repair Work Done ❑ Type of Pump= EastH.P. 16 +4 A? State Work Done Well Destruction El Well Diameter Sealing Material Itop 50') i Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 '� r. ll , Character of soil to a depth of 3 feet: "' `-" """- "" Water table depth^ r fl SEPTIC TANK ❑ Type/Mfg " `' '`'t .- Capacity No. Compartments ` PKG. TREATMENT PLT. Elw1 , Method of Disposal. P Distance to nearest: Well Foundationi±A - _' .Property Line LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number n -SUMPS '" ❑.. -Distance to nearest'—P Well r— Foundation 4 "' 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, state laws, and rules and regulations of the San Joaquin Local Health District. 4 r 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 California." , I The applicant mu tall for wired inspections. Complete drawing on Signed Title: Date: FOR D PARTMENT USE ONLY q '] Application Accepted by � Date �a�. Area V Pit or Grout Inspection by Date Final Inspection b Dates �s Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835 6385 - '�—�� 0l '_ Applicant- Return all copies to: Environmental flealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C. " 5201 L,,,let FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO p o`] + EH1324(REV.101E31 L�r�'^ycA b "~ •H/ O S�� l�//'! EH 14-26 1 Y