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r • APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Joaquin County Ordinance No. 549 for sewage or No. 1662 for well pump and the Rules and Regulations of the San Joaquin focal Health District. f3A v7,A Job Address 2 7`� "� �`rrZ//4�+ City Lot Size C �� PM Owner's NameD4kL4E+ *V 1309AAAJk p Address PhonjPhone Contractor L � Address �t License No. '� TYPE OF WELLlPUMP;• V � NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ;O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'D DISTANCE TO NEAREST: SEPTICI-.:TANK LINES" — DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ! PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Operi Bottom ❑ Manteca Dia. of Well Excavation /� Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing ; y � Specificatio s I 1`1 Public n Other n Delta ' - Depth of Grout Seal. t 1.1 Irrigation s _Type of Grout-.Approx. Depth I i Eastern -Surface Seal Installed by i f' Repair Work Done -❑--Type-of-P. H.P. i State Work Done i a . Well,Destruction+.� El Well Diameter Sealing Material (top 50') l ` r + Depth 'Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is ! ! ' available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units; Number of bedrooms .t s Character of soil to a depth of 3 feet: (;; ` i r ' Water table depth I SEPTIC TANK, r ❑ Type/Mfg Capacity No. Compartments PKG.TREATMENT PLT. ❑ 1 '1r �• Method of Disposal Distance to nearest: ,W.eII Foundation Property Line a - LEACHING LINE ❑ No. & Length of lines fl t5. I Total length/size FILTER'BED Distance to nearest: Well�_ u Fondation's ��' � `l �.� Property Lirie SEEPAGE PITS I I Depth ' + Size Number 4 SUMPS L-1 Distance-to nearer[ Well ° Foundation y PropertyLine DISPOSAL PONDS ❑ I hereby certify that I have prepared this application ana-,-iNt the work will be done in accordarice with San"Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health-0istrict.-:-- � t Home owner or licensed agent's signature certifies the�fc llowing: "I certify that in the perform' ance of the work for which this permit is issued: I shall-not F 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 must call for required inspections..Complete drawing on reverse side. g K Si ned X .. � Title: Date: i o F DEPARTMENT USE ONLY r Application Accepted by _ •*' Date f � Area Pit or Grout Inspection by Date 1 Finaf lhs6ection by ✓ Date' C� Additional Comments: t ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca"823-7104' ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 8ox'2009, Stk., CA 95201 k INFC FEE O AMOUNT DUE AMOUNT REMITTED LASH RECEIVED BY DATE PERMIT"NO. + EH 13-24 IREV,i/H 51 — / EH 1l-2e en! _