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} l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM' DATE ISSUED (Complete in Triplicate) Application is heteby 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. ! f 'Ro Job Address ]1,rte] c� ` 1 Nil Cit r� '•-- Yla�QLot Size ply Owner's Name Address - T � Phone ct al 1q�0 YY\-(' Address License No.15 _1�511Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI ❑ SYSTfy REPAIR ❑ OTHER ElDISTANCE TO NEAREST: SEPTIC TANK A�q -SEWER LINES DISPOSAL FLD. OP. LINE FOUNDATION Jy AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing jaa ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI�Public n Other I F] Delta Depth of Grout Seal _ 0��' Type of Grout�1 H`rrtgation Approx. Depth I 1 Eastern Surface Seal installed by Repair Work Done 4�-r Type of Pump Z1621 H.P. `� State Work Done Well Destruction ❑ Well Diameter-_ Sealing Material (top 50') Depth Filler Material {Below 50'1 I TYPE OF SEPTIC WORK:)"NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION t I Wo septic system permitted i# public sewer is available within 200 feet.! "installation will serve: ResidenceCommercial_ Other j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth E SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4 _ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation. Property Line SEEPAGE PITS 1 I Depth Size Number ~SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." { r The applican m st call for all req d intspections. Complete rawing on IR verse side, /� Signed X 'Title: v a_ tea" b. /IT� Date: V L. FO DEPARTMENT USE ONLY - t ` Application Accepted by Date lamArea U Pit or Grout lnspr ction by Date Final Inspection by Date) Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3W-3621 D Manteca 823-7104 C1 Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.;P.O. Box 2009, Stk., CA 95201 r 4 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. INFO } CASH r EH 1324 IREv,i w 51 S '� �-V ✓ (j �� /�/1�I �7 EH 14-26 W //