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APPLICATION,FOR PERMIT • A � a SAN JOAQUIN LOCAL HEALTH DISTRICT a. 1601 E. HAZEL T ON AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;ry (Complete in Triplicate} j 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. a � r City' PM_ JobAddress Ifls (901C Id . Owner's Name 0,V { AkA AR6 W)Address Phone j Contractor Address �� Q� __License No.'22�7i-77_ Phone__ TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 111 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I} ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1Dia. of Well Casing l ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F ❑ Public O Other ❑ Delta Depth of Grout Seal Type of Grout � I4 r ❑ Irrigation --Approx. Depth f, ❑ Eastern Surface Seal Installed by , l Repair Work Done ❑ Type of Pump H.P. State Work Done; Well Destruction ❑ Well Diameter Sealing Material (top 501 I ' Depth �° Filler.Material (Below 501 a TYPE OF SEPTIC WORK: NEW INSTALLATIN ❑ REPAIR/ADDITION'❑—DESTRUCTION 1No septic system permitted if public sewer is 1 I availablee witFiin 200 feet,) i Installation will serve: Residence_ Commercial`* Other -"I I Number of living units: Number of bedrooms r Water table depth Character of sail to a depth of 3 feet:- 1 SEPTIC TANK 171Type/Mfg f Capacity No Compartments PKG. TREATMENT PLT. ❑' Method of Disposal Distance to nearest: Well Foundation Property Line } LEACHING LINE LINo. & Length of lines � '" Total length/size i FILTER BED ❑ Distance to nearest: Well Fountlatio�n, 'Property Line SEEPAGE PITS ❑' Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 r 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.—__ •- - t 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, 1 shatt 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 call for all re 'red•inspe ions. Complete drawing on reverse side. _ r� I Signed X j Title: �.. .�.�� Date: FOR DEPARTMENT USE ONLY i Date Area Application Accepted by 1�/r'/�/-r�7 Pit or Grout Inspection by Date ` v Final Inspection by Date_ 1 /1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi-369=3621- ---I!] Mafiteca-823=7104'_ 07`acy'835-6385�Y Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 ; l FEE AMOUNT DUE' .- .'AMOUNT REMITTEDM" 'YK� RECEI1rED BY —. DATE PERMIT•NO. _ pie lei 17 + EH 13-24iREV.Vast F EH 1428