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y� APPLICATION FOR PERMIT SAN'JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES ? YEAR FRAM DATE ISSUED b (Complete in Triplicate:) _ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/;r install the work herein described. This application is t made in compliance withSanJoaquin County Ordinance No-549 for sewage or No. 1862 far well/pum Local Health Dist�r"i►ct- p and the Rules and Regulations of the San Joaquin Job Address 1 t% �f e b , City Lot Sizes E PM Owner's Name _ Address �.-10�" G�J�, - L,� Phone `S `�� Contractor I A-. Address License No.`.F TYPE OF WELL PUMP: N!EW WELL El _Phone WELL REPLACEMENT ❑ DESTRUCTION 2.),PUMP INSTALLATION-[] w SYSTEM REPAIR E3DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION OTHER ❑„ SEWER LINES DISPOSAL FLD. PRDP.`LlNE AGRICULTURE WELL - _ OTHER WELL PITS/SUMPS _ INTENDED USE- "- TYPE OF WELL 'PROBLEM AREA` CONSTftUCTIOIV SPECIFICATIONST ❑ Industrial — Open Bottom e. —II.Manteca sem. Dia. of_Well ExcavaWin.— Domestic/ a ❑ Private ❑ Gravel Pack ❑ Trac �. Dia .of V1lell•Casing 1 ❑ Public' Y Type of Casing �! ❑ Otfier ❑ Delta Specifications Depth of Grout Seal j i. 1 ❑ Irrigation ___Approxi Depth d Eastern I Type of Grout Surface Seal Installed by r . Repair Work Done ❑ Type of Pum"' H Well Destruction ,P State'Work Done J Well Diameter_ Sealing Material 1top 50') Dopth: i ler Material (Below TYPE OF SEPTIC WORK:,- NEW'INSTALLATION ❑ REPAIR " ; RUCTION_©;.{No septic system permitted'if public sewer is r Installation will serve: Residence available,within 200 feet.) Commercial, Other ' 4 Number of'livmg"units: Number of bedrooms �,. Character of s0i140"a depth of 3 feel: SEPTIC TANK ❑ ' Te/Mfg Water table deptft PKG. TREATMENT PLT. ❑ �i's'ija � ' Capacity No. Compartments nce to nearest: WQII Method of Disposal } Foundation Property Line _ LEACHING LWE ❑ No. & Length'of lines FILTER BED ❑` Distance to nearest: Wel! Total length/size # r F I Foundation Property Line J =-SEEPAGE PITS i j R *: ❑ Depth Size- .. SUMPS Number l ❑ Distance to nearest: Well DISPOSAL,•PONDS Foundation Property Line _ , < hereby certify that I have prepared this appli�cation and that the_work will be done_in.accordance-with San Joa ui coun rules and fegula`tions of the San J'o" in local Health District. Home owner or licensed agent's signature certifies the.followin -- q p-county state laws,=and employ an rk "I certify that in the performance of the work for which this permit is issued, I shall not R Y e person g such manner as to become subject to.workman's compensation laws of California." Contractoris 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 ) tion laws of California." r p y perslons subject to workman's compensa The ap licant must call for all regired inspections. Complete.drawing on reverse side. 9 ! ' igned � r i{ - Title: (5U) 4z-,r— 1 Date: 3- 97 FOR DEPARTMENT USE ONLY. Application Accepted byf -�. -- _ J�-- Pit "' ------------- 3;- 4 '•mac DBte •-..J` Area or Grout Inspection_by °� .s c> �- Date `' ` * —� —_ Final Inspection"by Date " Additrar►al Comments: ❑ 5tk .466--6781. ❑.Lodi.. 369-3621 "1 ❑ Manteca R23-7104 I ❑ Tracy' a35-63855 AppGcanf- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95201 e ' } " Y;ti,FEE,, Al K 1NF0 .e. AMDITNT REMITTED RECEIVED + EH 13-24'(REV.ties) - Q BY DATE PERMIT'No. k EH 14-28 � i