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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT €� j 1601 E._H�4ZE�.i 014 AVE., STOCKTON, CA k X Telephone {2091 466-6781 �P PERMIT EXPIRES TYEAR FROM DATE ISSUED , (Complete in Triplicate) �l\,?10 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d scribed. 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. gSZ31 .rob Address 01 IoLtACity ze PM Owner's Name Address`? q WCs ,��{ K�+ PhoneIF 0 Contracto Address t/ License No. ?— 7 Phone dz TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D s PUMP INSTALLATION El SYSTEM REPAIR >❑ OTHER ❑ DISTANCE.TOiNEAREST:,.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE iTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel-Casing 1. '' j ❑ Domestic/Private LlGravel'Packb�t \�k E] Tracy Type of Casing Specificationsr' , n Public t Cl Other 171 Delta Depth of Grout Seal Type of Grout 1. i I i Irrigation 4_"Approx. Depth I 1 Eastern Surface Seal Installed by LK a � Repair Work Done Type of Pump 5 ti�a H.P. � State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 501 t Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l 1 DESTRUCTION { I (No septic system permitted if public sewer.is { ! available within 200 feet.) r Iq -'-44 } 'V f Installation will serve: Repidence_ Commercial Other 'ci✓ 1. Number of living units: Number of bedrooms 1 { ; Character of soil to a depth of 3 feet: Water table depth Lmmmm SEPTIC TANK L]! Type/Mfg_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ - r _�T.. - ----�--- .�,— --_ —Method-of-Disposal, Distance to nearest: Well Foundation Property Line LEACHING LINE ❑i No. & Length of lines Total lengtWsize FILTER BED J IJ Distance to nearest: . Well Foundation Property Line . SEEPAGE PITS l l Depth Size _ Number SUMPS L Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS Ffl 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, an .666 rules and regulations of the San Joaquin Local Health D3ttict. Home owner or Ii is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe on in such�ma er as to become subject to workman's,compensation laws of California." Contractors hiring or sub-contracting signature certifies the f Ilowing: "I certify t at i the performan a of the rk for his permit is issued, 1 shall employ persons subject to workman's compensa- tion laws o California.' = i The applic nt must c for a 'red ins ti a dra ng on re s' Signed X le: Date: FT O��D�EPPA�ARTMENT USE ONLY Application Accepted byy�"�v Date, l Area Pit or Grout Inspection by Date Final Inspection by Date 6/ I Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY CK 0 DATE PERMIT'NO. +.EN 3-244gEV.r/e5f 5 � EH 14-26