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- ' APPLICATION FOR PERMIT x �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i. Telephone (209) 465-6781 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 4171 sewage Ordinance N Local Health District- �q o 9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin tliCzl•G4t�,� Job Address 414 Q City ✓ at Size PM Owner's Name 4 U FAddress Phone -2-9 Z-5 E=iw yw--TL E-` Contractor 4`�Gf�{rC-�cM� Addre ! License No.st�� Phone 1 -I3 �� TYPE OF WELL/PUMP: NEW WELL ❑ WEt-L REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �K_"2~ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �.�'fl�` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ITi Public F1 Other Cl Delta Depth of Grout Seal mut es I I Irrigation —.,Approx. Depth I 1 Eastern Surface Seal Installed by 1C.t.RQ 1F- Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 _ TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms f, . Character of soil to a depth of 3 feet: Water table depth (7 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m fo ired inspections. Complete drawing on re rse side. �. Signed X Title: Date: a FO DEPARTMENT USE ONLY Application Accepted by Date Area 12 / Pit or Grout Inspection by Date -r*•�c low,r x,04 v-4_- Q-L4 f 1 DtFinal Inspection by Date Additional Comments: ©it 4 . Bdr: s do,.,e tf ❑ Stk 466-6781 ❑ Lodi 369-36210 Manteca 823-7164 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r t yf FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. { INFO/� CASH U 1 I ,, 91 (V�� l + EH1�2glREV.iin51 �./�4 i 'L �V l� —alp, '