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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 <C, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��+�®� 1Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her CN1ed. �44� plication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rul e�uie '[r1e San Joaquin r Loco! Health District. //Z,0 - dOf - c% Job Address Cit � PM Owner's Name � C'� �.--Address � ® • / -�� - -- Phone 0 3 �# �r�• I Contractotg—,VAC/' Address License Nosa/033z Phone I I TYPE OF WELL/PUMP: i NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ - 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 SPECIFIC Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing��y+ Domestic/Private f�'GraveI-Pack—,,-, ❑ Tracy Type of Casing nL17A Specifications f'1 Public /�'Othe#4)*Ar/�7 Ll Delta Depth of Grout Seal �r►�{�� Type of Grout I I Irrigation - --Approx. Dep h I I Eastern Surface Seal Installed by Ka--Ah- h2 Repair Work Done ❑ Type of Pump V 461W H.P. State Work Done Well Destruction ❑ Well Diameter Sealing klaterial Stop 501 V Depth '1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 RLPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 'i Character of soil to a depth of 3 feet Water table depth Cr SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C1 Method of Disposal Distance to nearest: Well Foundation Property Line I �i LEACHING LINE ❑ No. R Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property tine SEEPAGE PITS { I Depth Size Number SUMPS Ll 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 Joaquin county ordinances, stq(�wws, and rules and regulations of the San Joaquin Local Health Di1trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this i f>{> `*shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hj�inl}�o��suP ddritracting signature r certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ pe s�gs�'s_u"Ct�t�*,%*van's compensa- tion laws of California." Qv,��1��,- ,' V i The applicant mu call far r i d inspections. Complete drawing on reverse side. �QP �k,I`.�' Signed X Title: /-5t / Date: Z I FOR DEPARTMENT USE O LY Application Accepted by n-v 1l1 ��---' Date Area 13 Pit or Grout Inspection by Data Final Inspection by"A l>WWL, Date t- Additional Comments: / r�� « '"'z G r fse I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-H85 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO y CASH ..EH13-241REV-ti A5) 3 5-Dv 3s'uo '(,y3s 3-3-� ��-931 EH 14-28