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I APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA a Telephone (209) 4616,-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED f . . (Complete in Triplicate) Application i if hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is 'r 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 x Local Health:District. , � ^ a Job Address. City Lot Size PM Owner's Named I Lv Address Phone y ��® � C�V4 Q �s� Phone Contractor 1 iA Y l�"�C`�14 L,l.-.�- Address Icense No. n e A- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ 11 DISTANCE TO NEAREST: SEPTIC TANK 1' ~SEWER LINES J DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial'I'[ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth 1-1 Eastern Surface Seal Installedby _ Repair Work;Done ❑ Type of Pump H.P. State Work Done_ ' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION Ll DESTRUCTION eptic system permitted if public sewer is (� { # available within 200 feet.) Installation4 will serve: Re -dence commercial Other 1 1 Number of living units: Number of bedrooms i Character hof soil to a depth of 3 feet:' t Water table depth lb ! 4 , SEPTIC TANK ❑ Type/Mfg, j Capacity No. Compartments If PKG. TREATMENT PLT. ❑ Method of Disposal �. w ' Distance.to nearesfi"f— Well Foundation Property Line ii iq LEACHING DINE ❑ No. & Length of fines iTotal length/size [` FILTER BED ❑ -Distance to'nearest- - Well Foundation - Property Line " -- - {t SEEPAGE PITS f I Depth Size _ _ Number { SUMPS' �! ❑ Distance to nearest: ! Well Foundation Property Line DISPOSAL PONDS ❑ t 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 Diltrict: Home owne or licensed agent's signature certifies tl4e following: "I certify`that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as tobecomesubject•to workman=s-compensation laws of California."Contractor's hiring or sub-contracting signature I ifies the following:"I certify that in the rformance of the work for which this permit is issued, I shall employ pe p p y persons subject to workman's compensa- ion la f!California.' ; The appl ant t ca for a re r d in ctions. drawing on verse sid .I r- Signe �� tle: � Date: i FOR DEPARTMENT USE ONLY Application Elk ccepted by I Date 2��e- Area vPit-or&out�lnspectio y Date Final Inspection by Date Additional Comments: /Vu 4- 62�Afz ��/ Pr ❑ Stk 466-1 6781 ElLodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave,, P.O. Box 2009, Stk., CA 95201 ?l FEE INFO AMOUNT DUE fAMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. .IE - •+.EH 13-24(REV.i i 8 51 EH 144-28 R t�X '~324''�� V v V ll�� (.Ju ..