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t r` f � ' y APPLICATION FOR PERMIT 5-/J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA N D �D W tj Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete•in Triplicate) v � A\ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describhis application is Local Health District. 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 r ` Job Address 202-7 ,- '1 City S TUCe.fO f7 Lot Size_�y X IoPM s _ X Owner's Name � Address Phone I Z11 fl? Contractor Address License NO. Phone_ f TYPE OF WELL/PU NEW WELL ❑ I WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRIC RE WELL WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO U N SPECIFICATIONS IL ❑ Industrial ❑ Open Bottom ❑ Manteca► Di. We ccavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 9 Specifications . ❑ Public ❑ Other ❑ Delt Depth of Grout Seal ( Type of Grout i EJ Irrigation �Qpprox. Depth astern Surface Seal Installed byr f Repair Work Done ❑ Type of Pump H:P. State Work p e I Well Destruction - ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 Q TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is Installation will serve: Residence— Commercial� Other available within 200 feet.) Number of living units: Number of bedrooms } Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r^ .-- LEACHING LINE ❑ No. & Length of lines Total length/size r s FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS EJ Depth Size Number SUMPS ❑ - Distance to nearest: Well Foundation Property Line,— _4 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 t• rules and regulations of the San Joaquin Local Health District. 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."Contractors 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 ` tion laws of California." p Y persons subject to workman's compensa- tion applicant must call for all req it d inspections. Complete drawing on reverse side. , Signed Q E l\ Title: � �� r Date: FO DEPARTMENT USE ONLY e Application Accepted by 0 tL Date Area Pit or Grout Inspection by Date Final Inspection by Date d ' Additional Comments: qqo ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104. O Tracy 8355-6385 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 INFO RECEIVED BY DATE. fiPERMIT'NO. + EH 18-24fFEV.1i951 . �� EH 74-28 ✓ ..- _.