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k _ f ' APPLICATION,FOR PERMIT SAN JOAQUIN,LOCAL-HEALTH,DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6181 PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED y. ^vF (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"a"' "Y .fob Address "4r City f.oo z Lot Size 41 PM . Owner's Name= �S �3� ,lei J Phon ; Contractor/ /Ad*'Address.p�tJ o"��j6� g License Na VY DJ-.,.7 Phone y� I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ®� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK a SEWER LINES _��_ DISPOSAL FLD./-S--O PROP. LINE 36 FOUNDATION' d AGRICULTURE WELL " r OTHER WELL PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 5 �L ❑ Industrial !fin Bottom ❑ Manteca pia. of Well Excavation - Dia. of Weil Casing i �stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �� _ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal e 7 or 4 ` >,s- Type r t ❑ Irrigation --Approx. Depth ❑ stern Sura a Seal Installed by ' a i V Repair Work Done ❑ Type of Pump a H.P. State Work Done_ ' `�' t Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth 1 Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system–permitted•if public sewer is is available within 200 feet j 4 1 �+ Installatip?i will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:' Water tablt depth "7 SEPTIC TANK Cl Type/Mfg Ca act P tY No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ti Distance to nearest: Well Foundation Property Line e LEACHING LINE O No. & Length of'Iines Total length/size '# { FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation - -Property Line ' DISPOSAL PONDS ❑ ` I hereby certify that I have prepared thisapplicationand that the work will be done in accordance with`San_Jvaquin county ordinances, state laws, and ! rules and regulations of the San Joaquin Local Health District. i f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the-work for which thispermit is issued, I shall not k employ any person in such manner as to become subject to workman's compensation laws of California." Contractor s'h`iring o%r,b-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subjec#'to-workman's compensa- tion laws of California." 4 The applicantjmt call for all required insp�1 & Complete drawing on reverse side. f Signed X "� ``� Title: as s< ��1i «, i Date: FORD PARTMENT USE ONLY Application Accepted by Date _lam �O Area k Pit or Grout Inspection'by ��_ Date Finni Inspection b O '`'Y QiC_Sr Date a Additional Comments: � i 4 ❑ Stk . 466-6781 `❑ Lodi 369-3621 ❑ Manteca 823-7104 r ❑ Tracy y835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK' - INFO.. _. -_ CASH. r RECEIVED BY _DATE �`'/'^• ` PERMIT' .'EH 3-24(REVy/EH2 [/ _ ND , [a s