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f APPLICATION FOR PERMIT SAN JOAQUIN LOCALMEALTH DISTRICT 1601E HAZEL T ONAAVE_ STOCKTON, CA t ' Telephone (2b9) 466-6781 j I ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 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. 1. Job Address �T��• -F City PM t Owner's Name ellss .Phone -l;ont a torte' 4 X Address�l/ x ��Z 7 License No. Phone 491� + i TYPE.OF WELL/PUMP: rTIEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP.INSTALLATION O SYSTEM 14EPAIR ❑ OTHER ❑ DISTANCE,TO NEAREST: SEPTIC TANK'- - - SEWER.LINES. _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL � OTHER WELL PITS/SUMPS I NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I ❑ Public '�" .k %� "'❑ O'tfier�' ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. Depth ❑ E tern _ Su al Installed by Repair UVQrk Done �J/Type of Pump H.P. �'3 State Work Done f Well Destruction_ ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s = available within 200 feet.) Installation will serve: Residence— Commercial— Other Number"of living units: Number of.bedrooms J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Q Type/Mfg` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal $ Distance to nearest: Well Foundation Property Lime t 4 LEACHINGS LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 141 SEEPAGE PITS. ❑ Depth .;. Size,- '#` -= Number x SUMPS "'" -y =O-•Distance-to nearest:'---W611 � Foundation— _mm. Property Line DISPOSAL PONDS ❑ t p hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andf rules and regulatio an Joaquin Local Health District. f Home owner or ' ensed agen'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 pe on in such ma'n as to become subject to workman' compensation laws of California."Contractor's hiring or sub-contracting signature certifies theJ Ilowing:"I certif that in the pert ce work f ?which th' rmit is issued,I shall employ persons subject i:o workman's compensa- tion laws`of Californi The applicant mu or equire ..r a wing on e - r-1y- Signed ITitle: ) i Aate: 1. 1 FO PARTMENT USE ONLY a i ,k Application Accepted by I DateA 1. "' Area Pit or Grout Inspection y Date }Finahllnspectiori by Date ,L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 '4p-Tracy 18i5 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 9 RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241 EH 1428 REY,1/8 Sl i - i