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x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 f 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. C- Job Address /� J S (/�/t01 -"�" City Lot Size 90 x�0D PMy Owner's Name & /7'� Fp—o " Address Phone 37-3-05,60 Contractor_ i�Ct1N Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �"x OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A ❑ Industrial ❑ Open Bottom 17 Manteca of Well Casing �vA Manteca Dia- of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fI Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ i I Irrigation _..Approx. Depth 1.1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ \ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLAT _ PAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is ~` Installation will serve: -Residence A Commercial— Other available within 200 feet.l Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments 2 PKG. TREATMENT PLT. FlCapacity— Method of Disposal FILL waw .&I" Distance to nearest: Well Foundation A .-- Property Line--�� LEACHING LINE ❑ No. & Length of lines Total-length/size FILTER BED ❑ distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state Maws, and rules and regulations of the San Joaquin Local Health Diltrict. 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 California." The applicant m aEl for ail required ins tions.��Collmplet� drawing on reverse side. Signed Title: O A✓/' Data: FOR DEPARTMENT USE ONLY Application Accepted by Data o 2 € Area Pit or Grout Inspection by jute Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy. 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO SH RE LVED SY PATE PERMIT'NO. +.EH 13-244FlEV.1i85} EH 14-26 4Y - f