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k '09 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 r (Complete in Triplicate) d 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 far sewage or No. i882 for well/ um and the Rules and Regulations of the San Local Health District: p p Joaquin dd Jab Address 1*�• � t l TV`G ff-P&) ; s o-2 S^0�3 D �'}2 `� �-_�� C.• - nY Lot Size PM _.Owner's Namey Address4r; '` •• Phone 3 Contractor Address TYPE OF WELL/FUM License No. Phone f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR Q^ DISTANCE TO NEAREST: SEPTIC TANK OTHER 0 i SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca pia, of Well Excavation. ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing ❑ Public :L Other ❑ Delta Specifications , Depth of Grout Seal Type of Grout �'I'rrigation —�pprox. Dep h ❑Eastern Repair Work Done 0— Type of Pump �h t H.P. Surf ce Seal Installed by _ Well Destruction ❑ Well Diameter " State Work Done fit^ Sealing Material ftop 501 Depth \ Filler Material (Below 50') TYPE OF SEPTIC Wo K: NEW INSTALI11"I ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic stem ' j p Y permitted if public sewer is Installation will serve: Residence available within 200 feet.) Commercial_ Other ' Number of living units: Number of bedroom`s Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg I T 'Water tabfe d6Vth— - "f _.� � PKG. TREATMENT PLT. Eli � CapacityNo. Compartments Method of Disposal i Distance to nearest: Well „a Foundation Property Line i LEACHING LINE ❑ No. & Length of!'linesl ;; r FILTER BED ; Total length/size ❑ Distance to-nearest:. Well Foundation o { Property Line SEEPAGE PITS ❑ Depth - I `•—Size I' Number,; SUMPS ❑ Distance,to nearest: Well •.l -�` � z -j, , r> DISPOSAL PONDS ❑ -Foundation Property Line I hereby certify that i have prepared this application and that ihe.wo4k will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �, Home owner or licensed agent's signature certifies the followin # employan g "I certify that in the performance of the work for which this permit is issued, I shall not Y person in such manner as to become subject to workman's Compensation laws of California."Contractor's hiring or sub-contracting signature tion l laws of California." certify that inhthe faerfoir�mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ++ +f � r The applicant at call for all requir } inspections.,Complete drawing on reverse side." Signed Date: F R DEPARTMENT USE ONLY Application Accepted by I Date Area t9 j Pit or Grout Inspection y Date Final Inspection by Date Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-$385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECENED fdY DATE PERMIT NO. -+ EN 13-24(REV.-1/65) EH 14-26