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1 I' / I APPLICATION FOR PERMIT l C� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 I PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) I a 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 ZST— �� --- City Lot',Size PM T, f / /` R. X dress _�C�/ 7"� fo (� Owner's Name _� Phone C I Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA1VKa�'*"^�'"SEWER LINES DtSP05AL`FLD. -" w– PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IPA ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing v D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ('1 Public Cl Other n Delta Depth of Grout Seal Type of Grout _. W I I irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter I Sealing Material (top 501 Depth f Filler Material'(Be10w 50'14 ' TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIRIADDITIONI 1 r DESTRUCTION fNo septic system permitted if public sewer is Y �'`�. - f available within 200 feet.I Installation will serve: Residence_ Commercial_ Other } ( Number of living units: Number-of bedrooms Character of soil to a depth of 3 feet: 1 Watertabledepth I SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments f PKG. TREATMENT PLT. O J� Method of Disposal Distance to nearest: i Well Foundation Property line 1 i € -- t LEACHING LINE ❑ No. & Length of lines Total length/sizer FILTER BED ❑ Distance to nearest: Well Foundation ! Property'Line a. SEEPAGE PITS l I Depth I Size1 -!!"Nurriber SUMPS L1 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 I rules and regulations of the San Joaquin Local Health District. I Nome 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 Californi "--- - The applicant must a AAA req in ctionsI Complete drawing on reverse side—Tit Z Y Signed X - Title: �/-n' � Date: 17- FOR DEPARTMENT USE ONLY I' Application Accepted by ;4, Date U Area Pit or Grout Inspectio # Daie`� S tt.,Final Inspection b� Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ 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 H RECEIVED BY ' DATE PERMIT'NO. INFO AAS r� sss---777 + EH 13-24(REV.i/n51 �sr ds �� / /a�� •,- 3�� EH 14-26