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- µ APPLICATION FOR PERMIT 11 SAN JOAQUIN LOCAL HEALTH DISTRICT { 1601 E. HAZE.T ON AVE., STOCKTON, CA M Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 n Joaquin Conty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. pp ,,,, Jab Address `� City Lot Size �-'6) � PM } Owner's Name t)0C1_691e.Address V -" Phone _ � r ContractorC ,Address PC) f cense No;� Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR•'❑ OTHER ❑ DISTANCE T-0 NEAREST:-SEPTiC•TANK-"mw"�SI=WER'LINES '"�' DISP0SAL`TCD:11 j PR'O'P!LINE 'a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r( ;INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1❑ Domestic/Private ❑ Gravel-Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Ottier4#,%_ 71 Delta Depth of Grout Seal Type of Grout--- I rout _I I irrigation -..�.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P- State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 501 t 1 - Depth Filler Material (Below 501 iTYPE OF,,SEPTIC WORK:INEW INSTALLATION REPAIR/ADDITION 17 DESTRUCTION I 1 (No septic system permitted it public sewer is available within 200 feet.) R! R drtstallation.will serve: Residence_�Commercial Other s Number of living units: Number of bed ar oms—!A _ r i r Character of soil to as depth of 3 feet: __.. � Water table depth ISEPThC TANK C❑ Type/Mfg Capacity C)(3 No. Compartments iPKG. TREATMENT PLT. ❑ Method of.Disposal �'FS Distance to nearest: Well 13n Foundation X51 Property.Line .LEACHING LINE Lo;f- No. & Length of Iii Total length/size Zda FILTER BED ❑ Distance to nearest: Well L574)_ Foundation 2'5 Property Line SEEPAGE PITS 1 ) Depth Size Number +E SUMPS` L1 Distance to nearest: .Well Foundation �` � Property Line DISPOSAL ONDS__. ❑ 1%v11-01 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 subiect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature "certifies the following ITcertify that in the perforrrmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif Tia. Jhe applicant sit/call for all r uired Anspections. Gomplate drawing oItiverse side. F T _ r Signed X ` - yy Title: Date: AKS aw R DEPARTMENT USE ONLY -Application Accepted by OALOV C Date Area Z or Grout Inspection by #� _� Final Inspection by 'Additional Comments: ❑ Stk 466-6781 4 " ❑ Lodi 369-3621 ❑ Manteca 623-7104 - ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P.O.'Box 2009, Stk., CA 95201 t , FEE INF AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY Y DATE PERMIT'NO. 1 +.EH 13-24 1 REV.1 51 !I�-7 EH 1428