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r lry. nsa r f ra APPLICATION FOR PERMIT (314K lJel4V Jj %. -- v. .v. �6 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 64,*._(t Telephone (209) 466-6781 Sa��efi y► �,, �d �� '^ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w It (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 T made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations,of the San Joaquin Local Health Distric `'- / r r1 I ° �[1 a City/" CLZ' Lot Size PM Joh Address # II b" Owner's Name + u" ` ' r Address" / License No. Phone Contractor � �?.5 a� J Addres TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM �gREPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 'f SEWER LINES '! DISPOSAL FLD. ROP. LINE Z� (� FOUNDATION /10 AGRICULTURE WELL_'70+OTHER WELL r` PITS/SUMPS >� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat'on }- !fir Dia. of Well Casing I ❑ Domestic/Private Gravel,Pack ❑ Tracy . Type of Casing c:dt Specifications�Irrigation Public /❑ Other ❑ Delta Depth of Grout Seal lType c�f Grout ---Approx. Depth ❑ Eastern Surface Seal Instal d by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler-Material01elow-50'}" TYPE OF SEPTIC WO K: NEW STALL'A/TIION REP IR/AD ITION ❑; DEST UC ION ❑ (No septic system permitted if public sewer is � ��- �" �� blwith in 00 f�e� Inst llation well serve: Residence Commercial_ Other f Number of living units: umber of bedrooms D II ``. '-� �\ ,� '� s_. ; , `Water table epth Character of soil to a depth of 3 feet: I' SEPTIC TANK ❑ .Type/Mfg �. Capacity\- N � • rNo. Compartments ..'_,' t' ' Method of Disposal ! i t PKG. TREATMENT PLT. Distance to nearest: Well Foundation Property;Lme_ �.----------�- Total length/size j .' .: ¢. i I LEACHING LINE [1) No.-& Length of fines FILTER BED _- ❑ Distance to nearest:- - Well Foundation Property Line i t r , r. �. a . ... Size 9— a"Y _ Number SEEPAGE PITS �`� �❑ Depyh - SUMPS--- —11 Distance to nearest:' Well— "Foundatiob — �' Property Lin i DISPOSAL PONDS ❑ _111k 9. .I ` r San Joaquin c6unty ordinances, st I 1k 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 f rules and regulations of the San Joaquin Local Health District. "� -s - 1—iiome—owner'or lieensed-agen—f signature certifies-the-following "I'certiiy`thai'in'the p�rfbrfnance`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 perfo'miance of the work for which this permit is issued,I shall employ persons subject to rkman's compensa tion laws of California." The applicant-must-call-forall required-inspections-Complete-drawing-on-rreveerrse-iide. �y . jam Signed Title: die v Date: �� `s _ FOR DEPARTMENT USE ONLY t - r r DatAj ��Area V,)Application Accepted by Date �Pit or Grout Inspection by Date-�� Final Inspection be Additional Comments: o,r ❑ Stk :466-6781 ❑ Lodi 36943621 El Manteca 823-7104 LJ Tracy 835-6385 .. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20 , Stk.; CA 95201 09 a FEE AMOUNT DUE AMOUNT REMITTED LA CASH IF RECEIVED BY DATE ,P'PERMITNO. D nl INFO / 9a-S1`��`� 4 .+ EH 13-24(REV.s/85) EH 1426 j 3 n+t ft1K5.7r�-r�v. � y rpt ri-y I--Arr Ao Tfav/�,✓[P . .