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k APPLICATION FOR PERMIT ` �1 «- SAN JOAQUIN LOCAL HEALTH DISTRICT r , 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 .��+ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1� (Complete in Triplicate} II 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 H made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1.862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. ;� I L/ r ` City Lot Size�J XLH PM Job Address Q Address Owner's Name '" �• -�+ Phone $ �, 3U t 3 Contractor ress License No �'S �` d Phone TYPE OF-WELL/POMP "TVEW'WEL'L:❑ ---` WELL!REPLACEMENT-(9-- -"DESTRUCTION-❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �f t DISTANCE TO NEAREST: SEPTIC TANK EWER LINES I DISPOSAL FLD. PROP. LINE FOUNDAT© AGRICULT L OTHER WELL PITS/SUMPS ; INTENDED USE TYPE OF WELL PROS EA CONSTRUCT( ECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well'Excavation Dia. of Well Casing r " 13 Domestic/Private ❑ Gravel Pack ❑ Tracy"" 'Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal =Type of Grout f t I I Irrigation #-Approx. Depth l I Eastern Surface Seal Installed by - € Repair Work Done ❑ '' Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing!Material (top 50') Depth Filler Material (Below 50') TYPE.OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAiR/A ITIOh61I I DESTRUCT( NQ7-�4No septic system permitted if public sewer is ailable within 200 feet.) Installation will serve:--Residence Commercial— Other „i, , .. w Number of living*units: 1 Number of bedrooms �l Ch4 a Number s_oii'ta a depth of 3 feet: 1 Water table depth SEPTIC TANK 1 ❑� Type/Mfg I Capacity No. Compartments I PKG.ITREATMENT PLT. ❑' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ .,No. & Length.of lines _ f Total length/size FILTER BED ❑ Distance to nearest: Well ` Foundation Property Line SEEPAGE PITS I I Depth Size .f Number # l SUMPS L] Distance to nearest: Well Foundation Property Line 1- DISPOSAL PONDS ❑ ' 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. ,f 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the_work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." _ The applicant st call for al .wired in ctions. Complete drawing on reverse side. tr l I E} ,f �I �a� Signed Title: _ D6te:1 s b 4rrQR DEOARTMENT USE ONLY Application Accepted by Date Area ~QJ `� -- Area j Pit or Grout Inspection by !�jPate Final Inspection by �' Date Additional Comments: �& G/// g ql 22 1 62(1-3 -,,.„,D.Stk-466.6781—.0-Lodi_369-3 1—D.Manteca-823-7104 ,_—❑Tracy.-835-BW5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 F AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT-NO. I N I,ol ]�j ¢�Q Q + EH 13-24 1REV.1�H 51 �Sr Q `� � (�{ �, A, V S• + r-jaU 00(B EH 14-28 - `