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f _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA €g Telephone (209) 466-6781 �1 ,` I () PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f� C�� (Complete in Triplicate) 1 Application is he+eby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Acaq&gwLot size , 1�LLr'l:aa. PM Owner's Name I� �/��LL Address V6 IV eAl Zr° Phone ` Contractor ZZ/&,MnS 40 Address License No.,��,b-Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR'❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK IKOU r SEWER LINES- — C'&&! DISPOSAL FLD, PROP. LINE 1�� EOUNDATION— _AGl`iICUL-TURE,WEL-L---N- --OTHER-WE-LC— Pk7S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia-'of Well Excavation ` Dia. of Well Casing ❑ Domestic/Private gGravel Pack ❑ Tracy Type of Casing__el�c Specifications 11410 i r'l Public ❑ Other n Delta Depth of Grout Sealop Type of Grout IYlrrigation 9�w�tr+ _--Approx.i DepthiIS�I Eastern Surface Seal Installed by 5 �[0 Repair Work Done ❑ Type of Pump —th�—ula H,P. I,4— ;_ State Work Done _ 1 Well Destruction ❑ Well Diameter Sealing Material itop 50 Depth Filler Material (Below-50, _ { TYPE OF SEPTIC WORK: NEW INSTALLATION- .'1-. -}-LWs,sepiic system permitted if public sewer is ..�- available within 200 feet.) Installation will serve: Residence— Commercial _._ Other ` Number of living units: Number of bedrooms f1�, Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well M Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well - Foundati6n-�^-�--Property-Hne— ------;i-�—--- 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 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." Contractor's 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 persons subject to workman's compensa- tion laws of California." The applicant must cal for all re uired inspection Complete drawing on reverse side. Signed X . Title: Date: et FOR DEP RTMIEN�USENLY /Z- 1 Applicatio�ny Accepted by w � Date �` � Area Pit or G(otJt Inspection by Date G 99 Final Inspection by ate IV Additional Comments: ❑ 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 . FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVEp BY DATE PERMIT'NO. - _ ,INFO p� r.EH 13-24(REV.I I K 51 E --t'75' ;y j� �•-/� l�yZ �'. "'-�,,,. H N-2B - . / 7 BQ� x