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APPLICATION.FO_R PERMIT SAN JOAQUIN;LOCALHEALTH DISTRICT 1601 E.,HAZEL R ON'AVEa, STOCKTON, CA Telephone (209) 466-6781_ i PERMIT EXPIRES 1 YEAR•FROM ©ATE ISSUEDY_� Y .. , if tal: w, �,. (COmplete.iny Triplicate} r. t, -lot' 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,coinpliance with San Joaquin County Ordinance No.549 for sewage Lor No.-1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.rc3�k. :if mjr,-!a to `-:_'q ;S' , yn>6lO '':x ;* ' r Job Address . Y _ 9_ City Lot,Size.i PM �. Owner's~Name / j/N%1%T� Address G[�� -Z&R.&3 _ Phone AIZQ Q - . :Contractor's Name_' ,Qn License No. 7l 55 _ Phone TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION D� PUMP INSTALLATION Vr OTHER/D{ �. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLD.__ PROP. ,LINE FOUNDATION ( { AGRICULTURE WELLI OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t 0 (Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public, D Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth '❑ Eastern Surface Seal Installed by S iRepair Work Done ❑ Type of Pump S U� H.P. _ T.[ State Work Done Well.Destruction ❑' Well Diameter _ Sealing Material (top 501 .� Depth - Filler Material (Below 501 4 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION-0 (No septic system permitted if public sewer is 4 available within 200 feet,) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a-depth of 3-feet:` 1Nater taLle depth } SEPTIC TANK ;❑ Type/Mfg _ Capacity T No. Compartments r ' PKG. TREATMENT PLT:❑ Method of =` Distance to nearest:' Well • Foundation Property Line C i, f .F •LEACHING LINE i 0 'No. & Length of lines Total length/size 'FILTER BED '"D Distance to nearest: Well Foundation l •%,Prop rty Line rimn �� 'i+ K t 'SEEPAGE PITS ❑ Depth Size Number 'SUMPS ' gip' Distance to nearest:" -,Well Foundation— -" Property Li "ir i•.. DISPOSAL PONDS Ll {�::!`diIT/uE 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-Joaquih Local Health District.- 'Home istrict: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, I 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 E certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California:" - :The applicant st,call for all required inspections. Complete drawing on reverse side. t T 11 :Signed (i{;. .® .� Title: . ��P . . . 7�/V e- .... - _�. �� Date: 1 FOR EPARTMENT USE ONLY Application Accepted by Date A Pit oC.Gee4 Iffection uy Date Final Inspection by Date< �. { Additional Comments: s` F D Stk 466-6781- ❑ Lodi 369-3621 ❑-Manteca 823-7104' D Tracy 835-6365 Applicant- Return all copies to: Envirorimen;al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 h , IN 7AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. L _ ;. _ q +EH 124(REV. EH 1428- i