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{; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E."HAZE T ON AVE., STOCKTON, CA ",Cg} ;Q Telephone {209} 466-6781 y� (� PERMIT EXPIRES '('YEAR FROM DATE ISSUED UU (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. Job Address Cit Lot Size v q =-"7 PM Address * 4 Phone try. Address yk -f License Phone ,�Z - TYPE OF WELL/PUMP: NEW WELL4❑ WELL REPLACEMENT ❑ DESTRUCTION ❑. .5d k PUMP INSTALLATIONSYSTEM REPAI� OTHER DISTANCE TO NEAREST: SEPTIC TANK-""`'rt` "SEWER LINES SPOSAL FLD. PROP. LIVE IJT— F6UNDATI6N'_" '";"''AGR'ICULTURE WELL y OTHER WELL "^= �—PITS/SUMPS - �r- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack 'El Tracy Type of Casing Specifications w 1-1 Public ❑ Other . H Delta Depth of Grout Seal Type of Grout , Irrigation __Approx.r D pth I 1 Eastern Surface Seal Installed by Repair Work Done E] Type of Pump_ b 2Q, di H.P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATID I 1 1REPAIH)ADDITION l I .DESTRUCTION (No septic system permitted it public sewer is 4 3a; available within 200 feet.i Installation will serve: Residence Commercial Other V Number of living units: Number of bedrooms W Character of sail to a depth of 3 feet:I + i r `r Water table depth SEPTIC TANK ❑ 'Type/Mfg' 4-a PKC. TREATMENT PLT. Ca aci *^o + x k� p No. Compartments I ❑ #.�. F k- s T Method of Disposal l � i S i� Distance to nearest: r Well Foun I Property.Line i LEACHING LIN_E ❑ No. & Length of lines t otal length/size f FILTER BED ,. ' O Distance to nearest: 'Well. Foundation Property Line SEEPAGE PITS I I Depth ' ' Size : ++� Number 45UMPS _ . C� _Distance to nearest; WeII ;Foundation Property Lin DISPOSAL PONDS ❑., "I�.� _ ! }." � �. ,� _ 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 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 t performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of C ornia." $_ The applica ust calLfar I requi nspections. Complete drawing on arse side ¢q ' Signed X (//{j Title: Date: FOR DEPARTMENT.USE ONLY Application Accepted by S(/� (/ Date Area Pit or Grout Inspection by Date Final Inspection by Date�� Additional Comments: ❑ Stk 466-6781 % ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 s Applicant - Return all copies to: Environmental Health Permit/Services 16011. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT-NO. r EH 14-24(REV.t/Ft 5] U �},� 00\��, //' EH 14-29 +t vv //�fJ�/ e7 0