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a` APPLICATION FOR PERMIT 61%1 SA7V?F fA�M it it SAN JOAQUIN LOCAL HEALTH DISTRICT (�7Slk T(3 1601 E. HAZE T ON AVE., STOCKTON, CA L �i Telephone (209) 466-6781 VA DU ii j PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ?-Oct `f3o-8 (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. 6,q06 W 5. 4G I , _ A Lot Size +dQ Ar—KE PM � J City Job Addres's', —s - Address Phone Owner's Name 6y- � I Address �Z�� f*' LC License No. s Phone_ Contractor �m TYPE OF WELL/PUMP: `;li NEW WELL ❑ WELL REPLACEMENT 1.1DESTRUCTION ❑ I PUMP INSTALLATION FlSYSTEM REPAIR LJ OTHER DISTANCE TO NEAREST: SEPTPROP. LINE IC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications g [i Delta Depth of Grout eal Type of Grout_--. F] Public '[TMJ ❑ Ot �p� a T I I Inigation L"..Approx. Depth 1.1 Eastern Surface Seal Ins ailed byAF Repair Work Done ❑ Type of Pump H.P. State Work Donet Well Destruction © Well Diameter Sealing MateriaIr l [top 50') �GG�FSS16��t:r P' Depth Filler.Material IBelow 50' -- ,� TYPE aF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DE 5 RUCTION l 1 INo septic system permitted if public sewer is it avails le wig f t __g �/4,e 400 �, / r��(L.fav 7ro Installation will serve: Residence Commercial Other IUGR aSrZ7� �/44_ ^- � Number of living units: .1' Number of bedrooms Character of soil to a depth 0'i 3 feet: wwulr a e epth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ��: Method of Disposal t' 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 Depth Size Number SUMPS LI ,Distance to nearest: Well Foundation Property Line 4 DISPOSAL PONDS ❑ .1p 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 I t rules and regulations of the San Joaquin Local Health Di§trict. i 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 became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify thatX the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of Califor t ." ?I The applicant i 'ons. Complete drawing o averse si� � f�� � Signed X Title: Date: OR DEPARTMENT USE ONLY Application Accepte!by —: Date Area �� Pit or Grout Inspection by �i. Date Final Inspection by Date 7 Additional Comments: ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Ma eco 823-7104 ❑ Tracy 835-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO � J +.EH 1324(REV.t/x 5) EH/4-28 Il'