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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE-LTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4%, (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. Jab Addre Al. 49, Ci �� Lot Sized PM •.. x _ f �� I� Owner's a L.�1�/Ei!'/� Add r Y- Phone? /� Cont Address _e eylos tm License Ii 7".yam// Z-7dV Phone y-,TVvfe TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J. PUMP INSTALLATION,4,-� SYSTEM REPAIR ❑ OTHER ❑ DISTANCEO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V.4Ka Iestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. D h ❑ Eastern Surf ce Seal Installed by Repair Work,Done 0 Type of Pum H.P. c3" State Work Done 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 I � availabler`within 200 feet.l 11 Installation will serve: Residence_ Commercial— Other Number of living.units: Number of bedrooms Characterofsoii.to a depth of 3 feet: Water table depth g SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal P ' Distance to nearest: Well Foundation Property Line `V I.. r : 1 _ F.W/q LEACHING LINEY ❑ No. & Length of lines Total length/size V1 FILTER BEa 9 ❑ Distance to nearest: Well Foundation - Property Line SEEPAGE PITS O�1Depth' "'L "" Size Number SUMPS .rte ED,Distance to-naaresti �Welf �y Foundation Property Line DISPOSAL PONDS ❑ � I hereby certify that•I have prepared this.-application and that the work will be done in accordance with Sari,Joaquin county ordinances, state laws, and eg rules and rulations of the San JoaquiLocal Health District.. Home owner:or licens4agent's sigrlature 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:"1 certify that in the performande;of.the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif rnia:'', The applicant �St calFfor.all required�ctiC plate drawing.on r rse side. c Z Signed Title:. / Date: FOR DEPARTMENT USE ONLY 0 a� Application Accepted�by Date Area Pit or Grout Inspection by a Final Inspection by Date Additional Comments: ❑ Stk 466-6781 1❑ 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 'INFOFE FEE - AMOUNT DUE '4 AMOUNT REMITTED GA81i RECEIVED By DATE PERMIT`NO. + EH 1324 I REV.f/B5) — �--^". ��`^ =3�._•-F /D 3 EH 1428 5c ..� x l