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#' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE. T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 worts 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. Job Address a �R _ - City Lot Size PM Owner's Name �� Address % �1 �- Phone Contractor ddress G J �"�- License No./ 3 7 PhoneK6- 9� TYPE OF WELL/PUMP: NEW WELL / WELL REPLACEMENT ❑ DESTRUCTION ❑ j$S- �a51 W, -K. PUMP INSTALLATION I SYSTEM REPAIR ❑ OTHF5R ❑ �1 f C -O =- —/ t��DiSPOSAL-L-D:��-"-•PROP"L1NE-,!! DISTANCE TO�?'�ARc'5•T'�^Sc""F'FIC�A'NK�-- •,- SEWEWL-INES ds FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / If Co Ll Industrial ❑ Open Bottom C-1MantecaDia. of Well ExcavatioA _- Dia. of Well Casing �r Domestic/Priv,a .Gravel Pack ❑ Tracy Type of Casing r� Specifications fl Public F gther f-1 Delta Depth of Grout Seal So Type of Grout I I Irrigation �05!_,Approx, Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump - H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material itop.501 Depth Filler Material iBelow 50'1 TYPE OF SEPTIC iWORK: NEW INSTALLATION I:1 REPA] R/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is I available within 200 feeO . Installation will Number of livii Character of s4 SEPTIC TANK PKG. TREATMEI rrve: Residence ___W_ Commercial _ Other units: Number of bedrooms to a depth of 3 feet: t❑ Type/Mfg Capacity= PLT. ❑ _ -r Distance to nearest: Well Foundation Water table depth No.' Compartment Method of Dispos Property Line LEACHING LINE ❑ No. ,& Length of lines Total length/size_ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 's 1 1 Depth Size Number -�- SUMPS .1 ❑ Distance to nearest: Well 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 Joa�countyrdinances, 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 inthe performance of the work fpermit is issued' Ishall not employ any person-in-such-mar�r`Ns tipb6-C]me"subiect`'toworkman's compensation awsaf`Califomia." Contrar sub -contracting signature certifies the following: '9 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 t cal for all r ui d inspections Complete drawing on reverse side. # Signed X �_� -Title: Date: U 4 i FOR DEPARTMENT USE ONLY Q �^ Application Accepted by Date 10? U o �}rea Pit or Grout Inspection by r Date +� Final Inspection by Zd4e221I Date Additional Comments: , ,/' ❑ Stk 466-6781 ❑ Lo 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Petmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13-24 IREV. i s EH 14-2a FEE INFO AMOUNT DUE AMOUNT REMITTED CK SH RECEIVED BY DATE PERMIT NO. ds L�L1b �� ` s