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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) QRZ wo_0 I . 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- .�dZ� Tl'r 5*c _/V W.�S Cir-(u L-'T7�--C(� � 44 Job Address City -D-4-CM Lot Size PM 1 \ 9 `I2Phone J 1 Carne &n 2 }�r 1- Address Owner's Name � - �} ,�y } V llt° C7+`F - License No.'�37 Phone�71 —� Contractor I ll � { Address �� J - _ _ I WELL REPLACEMENT C1 DESTRUCTION OF WELL/PUMP: �J� NEW WELL ❑. SYSTEM REPAIR ❑ OTHER ❑ POMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -}y AGRICULTURE WELDt1H� OTHER WELL`V irk PITS/SUMPS FOUNDATION, AREA -CONSTRUCTIONS ECIFICATIONS ! INTENDED USE TYPE OF WELL PAeB EW t Industrial <� ❑ Open Bottom ❑ Manteca Dia. of \4fellaeeatratirtrt or:rtds- ��ah' Dia. of Well Casing ti Type of Casing + SRecifications ❑ Domestic/Private ❑ Gravel Pack Tracy yP g -to cf�., �7T 1 e of GroutZ!e c PrltP -_. ❑ Public ❑ Other I n Delta Depth of Grout Seal JI' r1\ ,+ �.Approx. Depth t I Eastern Surface Seal Installed by 1 1 Irrigation H P State Work Done Repair Work Done ❑ Type of Pump j r Sealing Material Itop 50'1 ! I Well Destruction ❑ Well Diameter g Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION l 1 DESTRUCTION I I (No seperw thin 200 feetstemrt}ed it public sewer is -r Installation ill serve: Residence Commercial— Other r. 'i Number of living its: Number of bedrooms Water table depth Character of soil to a th of 3 feet.f Capacity No- Compartments SEPTIC TANK ❑ Mfg Method of Disposal PKG, TREATMENT PLT. ❑ ij Distance to nearest: Well Foundation Property Line 4 Total length/size LEACHING LINE LINo. & Length of lines ❑ Distance to nearest:- Well Fo ation Property Line FILTER BED " I I SEEPAGE PITS Ii Depth Size _ er SUMPS ❑ Distance to nearest: Wel foundation Prop e� l 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 l 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 taws of California." The applicant st c 11 for II required ins ctions. Complete drawing on reverse side. r �� I Title: `1 ge�lo f_4 - Date: Signed X DEPARTMENT USE ONLY } Date O ea Application Accepted by r� l to ' Pit or Grout Inspection by Date Final Inspection by Additionat Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Appllcant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH I' INFO s5. u-z� to + EH 13-24 1REV.5 I EH 14-26 _ _