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F � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -2 -- fO L3 'U� 1601 E. HAZE ON AVE., STOCKTON, CA 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 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, r�IF O O t (J[-77-4- l�r�. /y� b 23 -- p l v-b f Job Address /��1_,r4P_ :kc-� city 47io-t Size PM �.. 2 105-5'- Owner's Name �-AA%V Jl1 U FAddress Phone Contractor kke ! I 411111dress r " '' u e { ticense No. I`!1 S 5CZ Phone 3 7 1-30 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Il��n DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION f Zi AGRICULTURE WELL OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W L] Domestic/Private ❑ Gravel Pack �_ ❑ Tracy Type of Casing T4,dt..- Specifications /01F Public n Other ❑ Delta Depth of Grout Seal T pe of Grout _. I I Irrigation Approx. Depth A Eastern Surface Seal Installed by Repair Hyork Done ❑ Type of Pump H.P. State Work Done _ (♦j Well Destruction ❑ Well Diameter Sealing Material {top 50') I I Depth Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foun ion Property Line LLL? SEEPAGE PITS I1 Depth Size Number SUMPS 11 Distance to nearest: Wel! Foundation Property Line 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 Califor ia." The applicant I all req Ted inspe ions. Complete drawing on rev rse side. Signed X Title: Yk Date: y FOR DERARTME T USE ONLY Application Accepted by Date `4 r� Area Pit or Grout Inspection b Date;�w Final Inspection by Date Additional Comments: __/vmcl !/2W // be S) ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑fAantoca 823-7104 ❑ TraW 836385 ��/�`�� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO MOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE "PERMIT'NO. +.EH 13241REV.1iK5l /l1 EH 1428 .I �-- •� - +�'(J ..