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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' k 1601 E. HAZE T ON 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. }+Q w Job Address ID ` �. i#Kl� � CityeawAetot Size PM Owner's Name �f Address �O �X Z-3Phone /J 1 C] Contractor Address 4 AZ&ense No.3J/ !j3(k_ Phone 3Lk TYPE OF WELL/PU NEW WELL)a WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES T1- DISPOSAL FLD. PROP. LINE IFOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO s © Inddi"trial pen Bottom El Manteca Dia. of Well Excavation i ^ Dia. of Well Casing .Ool�estic/Private Gravel Pack ❑ Tracy Type of Casing jSpecifications C rr I'i P,,tblic ❑ Other Cl Delta Depth of Grout Seal /7 „Type Grout �r�� i� i v I I-frrigarion t---Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done L7 Type of Pump H.P. State Mork Done'_ / i.k Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION I I DESTRUCTION 1 1 INo septic system permitted if'public sewer is ' t available within 200 feet.) 'P Installation will serve: Residence____Y.f Commercial_ Other :Number of living units: F Number of bedrooms l if t R c I { 1 Character of soil to a deptft of 3 feet: � �\ epth \\ SEPTIC TANK In Type/Mfg Capacit -_ - No.'Compartments 1 . . — �.�„� _. t PKG. TREATMENT PLT. ❑ �� Method"of-Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE ❑ No. & Length of lin ` Total length/size ' FILTER BED O Distance ton st: Well .. Foundation Property Line SEEPAGE PITS ZD Size _ Number SUMPS 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 Di§trict. ; 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 Califor ia."" ! The applicant mu c �pectin eta drawing on reveYse side. r Signed X ills: - rn� /19 nate: . FOR DEPARTMENT USE ONLY Application Accepted by i N q Date Area Pit orro Inspection by Date r Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INFO AMOUNT DUG AMO REMITTED CASH RECEIVEDN Al DATE PERMIT NO. t ♦.EH 13-24(REV.I/H 57 O EH 14-28 U t• ~