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t APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRIC �j I 1601 E. HAZEL T ON AVE., STOCKTON. CA Q� Telephone (209) 466-6781 v A 1�8� L� ,3v PERMIT EXPIRES 1-YEAR FROM DATE ISSUED f (Complete in Triplicate) ENV%RON ES�R\AGES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installthe pherdescribed. This application is tein made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ruleswork and Regulations of the San Joaquin f Local Health District. Job Addres - d 0 — Cit Lot Sire (M Owner's Name _ �-� Address r �� Phone Contract /� Q�3a ��' ! � Address l7 Lir` License No. 39 43` Phone --2&Y 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 FOUNDATION AGRICULTURE WELL -OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f'1 Public t Specifications 17 Other . t f� Delta Depth of Grout Seal Type of Grout I I Irrigation w Approx..Depth I i Eastern f Surface Seal Installed by 1 - Repair Work Done ❑ r`T " 'r Type of-Pump,�.�� *,_ H. �/1�--- State Work one Well Destruction ❑ Well Diameter - Sealing Material (top 50') Depth j Filler Material (Below 50') 0 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION I i DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence. Commercial Other 1k, d —Number Number.of.living units: Number of bedrooms Character of soil to a"depth of 3 feet:_ _ — - _ _Water table depth SEPTIC TANK ❑ Type/Mfg Capacit Y No. Compartments T- PKG. TREATMENT PLT. ❑ �� •: 1 Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El 'Distance to nearest: Well Foundation Property Line SEEPAGE PITS a. 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation 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 Diltrfct. 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." . The applic us call for all re fired inspections. Complete drawing on reverse side. Signe Title: A90!1� Da te: FOR EPARTMENT USE ONLY Application Accepted by � Date Area Pit or Grout Inspection by Date Final Inspection by - Date'l1•a fs� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 923-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 r FEE AMOUNT DUE AMOUNT REMITTEDCK INFO CASH RECEIVED BY DATE PERMIT'NO. t.EH 13-24 IREV,t/N 57 �� EH 14-2$ - y