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f} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAA-L'TON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES'7'YEAR�FROM-DATE ISSUED (CoMplete in Triplicate} F 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 Ryles and Regulations of the San Joaquin j Local Health District. Job Address —L77. 9,9 tTI) City Lot Size y 1 PM Owner's Name �.� L _�� . F Address'- Phone Contractor \A L—'Lb�R\—L Z1)S_Address - ~ License No. 3c& Phone TYPE OF WELL7PUMP:— NEW'WELL"❑— WE R PLACEMENT ❑ DESTRLICTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,LJ, - OTHER ❑ � r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE iE FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS t` r — .��y INTENDED-USE.TYPE—OF_WEL-L P-ROBL-EM-AREA.=CONSTRUCTION--SPECIFIEATIONS-.%ft- + ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i 0 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f ❑ Ir=rigation —Approx. Depth ❑ Eastern Surface Seal Installed by r j 4. i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ' f Depth —Filler Material (Below 50'1 � h _ TYPE OF SEPTIC WORK: -NEW INSTALLATION PAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—Eommerci al" -*Other' Number of living units: —I-- Number of borooms Character of soil to a depth of 3 feet: L �'1- Water table depth . SEPTIC TANK N--Type/Mfgg Capacity i No. Compartments f PKG. TREATMENT PLT. ❑ : >t �,1 ; �/ �� [ l" C 7JC `� Method of Disposal j Distance'to nearest: " Well Foundation Property Line -r f LDD s LEACHING LINE 1No. & Len th of )tries F'�� ' f i ' 9 L Total`length/size FILTER BED ❑ Distance-to nearest; Well, Foundation Property Line : SEEPAGE PITS N(]epth Size-- Number ,, f� �,��-., SUMPS ❑ Distance•tolnearestWell''" "�� Foundation Property Line _-.. '4 DISPOSAL PONDS 4❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and:regulations of,the Sari`Joaquin Local Health District i 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 permifis issued;<l`shall employ persons subject to workman's compensa- tion of Califor The applican, t call f all�ruireinspect s. �pl.,torawing on reverse side. "Signe Title: " Date: oC V D i 4 FOR DEPARTMENT USE ONLY :> Application � k' PP Accepted P b Y 'Date � � Area C)Pi r or Grout Inspection by Date Final Inspection by A Dat e Additional Comments: r ❑ Stk 466-6781 ❑.Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ; _JFEE r � INFO AMOUNT.DUE AMOUNT REMITTED CASH RECEIVED BY- DATE PERMIT"ND. , + EH13-21(REV.I/65) -I�l EH 1426 - - llllll��{ 11��