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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AL_ 5 1984 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, Job Address Q 1✓ PA City r- ' o Lot Size PM Owner's Name LL I Address " -S.XJ m 6 _ r Phone L9321--Q 490 i4 w f •' Contractor's Name' �.+. License No. I �QT Wl x Phoned v V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-'El - DESTRUCTION ❑ PUMP INSTALLATION ❑ = .. #"SYSTEM'REPAIR N OTHER ❑ DISTANCE TO..N4REST: SEPTIC TANK y_ SEWER LINES DISPOSAL FLD. ' PROP.-LINE I FOUNDATION --AGRICULTURE WELL OTHER WELL I PITS/SUMPS �` { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSi i; `•.'. ,.°� � ❑ Industrial ❑ Open Bottom ❑ Manteca Dia-.df Well Excavation i iDia.-of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy',, - Type of CasingSpecifications ❑ Public ❑ Other ❑ Delta `� Depth'of.Grout Seal, __ Type of Grout ---Approx.Approx. Depth El Eastern Surface Seal Installed by r Repair Work Done Type of Pump H.P. State Work Done Juk"'We f CQ Qi1e' .S WellwDestruction ❑ Well Diameter Sealing Material (top 50') 1 hd -jA Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial' —Other "- Number of living units: Number of bedrooms `• ' 9 .» .� Ly 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 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Pro i party Line , s 4 r SEEPAGE PITS ,.-. ,. El—Depth. - _�Size_ _ Number �____�•4„�� a SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ z 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, 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 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." i The applicant u call for all requ'ed i spa ns. Complete drawing on reverse side. Y Signed X auTitle: Date: f FOR DEPARTMENT USE ONLY Application Accepted by Date � Area yPit or Grout Inspection byDate -'Final Inspection Date�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63a5 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOU T REMITTED CK RECEIVED BY DATE PERMIT'. INFO �CASH J A A9 24{REV.1el831 t _ 7-5— � 4•� l//J� 1 r