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3 1i APPLICATION FOR PERMIT SAN JOAQUIIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 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. I'� �J Job Address ✓� �i�iC/fLJ City Lot Size PM t Owner's NamxeA I.E✓r%lt/ Address I�,d I 4J, 19 Ldp ---- Phone f X` b Contractor /Address & a P License N9/L2.37.,3 Phonr? TYPE OF WELL/PUMP: NEW WELL 21' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK NiA_&/ SEWER LINES DISPOSAL FLD. // PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 47 4f� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 11Industrial ElOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing / ❑ D%omestic/Private JAGravel Pack ❑ Tracy Type of Casing Specificationsy� ❑ Public F-1Other 171 Delta Depth of Grout Seal 0_.. Type of Grout&-0 Irrigation _Approx. To I k Eastern Surface Seal Installed by i Repair Work Done (2' Type of Pump `s-t.-C H.P. -� State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 50 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet./ �\ Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms O Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line CC_— PITS I I Depth Size Number SUMPS LI 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, 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 in the performance of the work for which this permit is issued, 1 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 parformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion ilaws of California." The applicant st c I for all re aired inspections. Complete drawing on verse side. Signed X_�_ 1e: C� Date: OR DEPARTMENT USE ONLY Application Accepted by •�.a Date Area iw� a-lCr�e.R - Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 1INFO AMOUNT DUE AMOUNT REMITTED CK 9 099 CASH RECEIVED BY DATE PERMIT'NO. + „ Q` - W.�•/U�U4 +,EH 13-24 IREV.1/R 51 �f"1y} L,�Q 0 17- �,,,i,�/ (r`'�'1p EH 14-28 ]"IV J i ni1