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r1 � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ C Y 1601 E. HAZE T ON AVE., STOCKTON, CA 95 Telephone (209) 466-6781 1950 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEP V IRONI ENTAL HEALTH (Complete in Triplicate) PER N1!T/SERVICES 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 Ordinanre.No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �( 37-3.5-0. C t,.e etl4' 1'C! `� City C Lot Size PM �1 Job Address � '� ,t J1rAQ ✓ bg wl i� /.! F C 4 et d Phone Owner's Name � Address / Contractor f7` I>i Address �! `� License No. —Phone TYPE OF WELL/PUMP: NEW WELL' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O H T ER ❑ DISTANCE TO NEAREST: SEPTIC TANK -t SEWER LINES DISPOSAL FLD. KOil t,PROP. LINE OT _ M,'AGRICULTURE WELL -" HER WECLR" ,PITSISUNIPS`_�"""""`w'""" OUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATICy l( Dia. of Well Casing (� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �Domestic/Private ravel Pack Tracy Type of Casing P .• Specifications t`7 Public �GOther alta Depth of Grout Seal Type of Grout� 4 I I Irrigation l�. -&7 S��Apprax. Depth l I Eastern Surface Seal Installed by_ C J�, — ( Repair Work Done ❑ Type of Pump H.P. State Work Done It Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Illk Number of living units: Number of bedrooms ,1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments N PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line I I �• LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property tine SEEPAGE PITS I I Depth Size — Number %- .,_,,,r,�SUMP-SY -, _.. ; .L� Distance to nearest; ,, WeH Foundation Property Line DISPOSAL PONDS ❑ ° hereby certify that f 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 Di'Mrict. 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 compenss, tion laws of California." The applicant st cal for OWreq ire inspections. Complete drawing on ri arse side. ��' Signed X Title: I/ — Date: O DEPARTMENT USE ONLY zI� Application Accepted by Date .2— Area C� Pit or Grout Inspection by Date Final Inspection by Date `� /0 Additional Comments: ' 1�0 / f 2_2~ f 2. ElStk 466-6781 ❑ Lodi 369-362197 ❑ Manteca 823-7104 ❑ Tracy _835-685 Applicant- Return all copies to Environmental Health Per it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 _ �u fud llou� .,o [��vtkf pal n. cltCk 'et(ve fir= k-,s P, FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO r7 +.EH 1324 I REV.1/0 5) - _-_ EH 14-2d