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�V" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES Y YEAR FROM DATE ISSUED fComplete 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. ! r: Job Address 1 City Lot Size PM Owner's Name r111 Address 7 Phone Contractor I ih Address P T• " � License No.q 3131 Phone .� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK �`�-O' SEWER LINES DISPOSAL FLD. PROP. LINE E f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS/S INTENDED USE, TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIO S f 1 ❑ Industrial >4 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t'r, _ Specifications � 1-1 Public " n Other CI Delta Depth of Grout Seal Ty of Groot e elY _ I i Irrigation � c�_&.•Approx. Depth 1 1 Eastern Surface Seal Installed Repair Work Done ❑ Type of Pump H,p, _ Mate Work Done_Well Destruction 'Well Diameter �`�Z._ Sealing Material (top 501 - Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INST-ALL-A71ON I I REPAER/ADDITION I I DESTRUCTION t I (No septic system permitted if public sewer is ` § available within 200 feet.) Installation will serve: Residence_ Commeicial-' Other U Number of living units: Number of bedrooms Character of Sol[to a depth of 3 feet: Water tattle depth SEPTIC TANK ❑ Type/Mfg YN Capacity No. Compartments PKG. TREATMENT PLT. ❑ ✓`� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest• Well Foundation Property Line 7F SEEPAGE PITS i I Depth Size Number SUMPS Ll 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 Di1trict. Home owner or licensed agent's signature certifies the following: -f 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 applicant myst call for all requir d inspections. Complete drawing on reverse Side. Signed Title: 1 17L.e Date: � `7 R DEPARTMENT USE ONLY !! Application Accepted by Date —b� D Area Pit or Grout lnspection.by� ' Date /G G Date �C -- _ - -- ..- Final Inspection by / �� Additional Comments: ll A CA( L7 Silk. 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 JuG—f L Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.,Hazelton Ave., P.O. Box 2009, Stk.,'CA 95201 S%ou AiAAP 36-,oo pose-v cho-i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO GASH i t.Ek 14-28 EM 13-24 IREV.7/H 5i I !I'��//D 1 V�y +�T N��D y p p 1 O �- -p