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� f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT-ON AVE.,'STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED r yr u (Complete in.Triplicate): x Application is hereby made to the San Joaquin Local Health District for a Oermit 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. 'r 1" Job Address '? 2 3 City / Lot Sizey40 PM Owners Name 'L L Address J { Phone Cont ract&} S Addressc3 5oN lvSyj y Phone��746'0License No TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ r r- W -•-:- .--:�-g, ---„PUMP-INSTALLATION.p.--- -SYSTEM-RE PAIR”-Q - Y----;-OT+IER"~❑ DISTANCE TO NEARESY:;SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE e` # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS £"INTENDED USEY TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ L2 Industrial .0 peen Bottom L7 Manteca—Dia.of WeILExcavation _ - - Dia. of-Well Casing YV ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ❑-Public ❑"Other J ❑ Delta Specifications r Depth of Grout Seal Type of Grout ❑ Irrigation f Approx#Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction i ❑ Weif Diameters Sealing Material (top 50') Depth Filler.-Material-(Below-50') TYPE OF OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRUCTION ❑ (No septi system•permitfed if public sewer is available within 200 feet-) Installation will serve: Residence_ Commercial__ Other Number bf;living units: Number of bedrooms s Character,of,soil to a depth of 3 feet: �• Water table depth { �' SEPTIC TANK' �`� ❑ Type/Mfg �" Capacity No. Compartments' I K�G.;TREAT_MENT`.PLT. ❑ �F� r j Method of Disposal jj Distance to nearest: Well Foundation Property Line / Ua'' No& Lerigih of lines a� FILTER BED Total length/size T { , .,L'I�bistance to nearest: Well`. l �" ;, Foundation_- Property Line O . i. y,SEEPAGEyPI7S ❑ ,Depths ' Size w. t Number SUMP S ❑ Distance tornearest� yVellr._.—� _foundation-- --=--pPro a e DISPOSAL PONDS - ❑ ! - P rty-Line I heiebycertify-that-I have prepared this application and that the work will be done in accordance with San Joaqujn county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: S t employ an "!certify that in the performance of the work for which this permit is issued, I shall not p y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r certifies the following: "I certify that in the_p 'mance of the work.for.which this permit,is issued', I shall employ tion laws of California." p y Persons subject to workman's compensa- The appfican ust call or all re ve ions. Complete drawing on ese side. Signed a;F Title: Od Z .Date: _ ; X ;try t±. F R EPARTMENT,USE ONLY Application Accepted i %[J4 ! Date _ Area { _ Ff Pit or Grout Inspection by l� Date �' Final Inspection by Z�!��i�; Date� Additional Comments:r ❑ Stk 466-6781 'C] Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all'copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ak i y � FEE r AMOUNT DUE AMOUNT REMITTED CK , INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 1324�SREv.I./.'a 51 _ + EH 14-28 +,r ,i �`