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* L_ APPLICATION VOR PERMIT SAN JOAO.UIN,LOCAL HEALTH DISTRICT 1601� E. HAZELTON AVE., STOCKTON,'CA'pre,C,Ir r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED „{ N (Complete in Triplicate) Application is Hereby made to the Sart 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 RegufBtions of the San Joaquin Local Health D,istrict., f a � Job Address i� fICCity �?�Lot Size of PM Owner's Name - y VI.- r r L`�� t�-Address Phorte '�� i � Contractor's Name iAb License No. Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El AUCTION © s PUMP INSTAL LATIO ❑ SYSTEM REPAIR QTJIER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL�f=Li _, PROP 1II1lE FOUNDATION AGRICULTURE WELL OTHER WELL _ r PITS/SUlVFPS INTENDED USE TYPEIOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION :�^ - t ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia: of Well Excavation k Dia..6f We1l.Caaing `J1 Domestic/Private. ❑-Gravel Packer—^""b Tracy -""':" "Type of Casing = Specificetlons.;� ❑ Public ❑ Other E3 Delta Depth of Grout Seal Type of Grout, ❑ Irrigation i --Approx. Depth ❑ Eastern Surface Sal Installed by Repair Work Done , Type of Pump c H.P. State Work Done G 'Y i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 1. � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ M6 septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence Commercial_ Other ; Number of living units: i'Number of bedrooms 1. Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i 'Method of Disposal Distance to nearest: Well Foundation Property Line a - LEACHING LINE ❑ No.: Length of lines Total length/size - FILTER BED " ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS Q Depth Size " Number SUMPS a ❑ Distance to nearest: Well ! Foundation Property Line T,, DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the wo*will'be done in accordance with Safi Jaaqurn`counry 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."Contractors hiring or subcontracting 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 Cal'rfornia." The ap call fpr all req ' d inspe ons. C plate drawing on rse side. Signed Title: Q Date .i.. .', � • w 'fit FOR DEPARTMENT USE ONLY Application Accepted by Date -87 Pit or Grout Inspection by I Date Final Inspection by Data z Additional Comments: ' ❑ Stk 466-67$1 ❑ Lodi 369-3611 ❑ Manteca 823-7104 ❑Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk.;CA 9520] 11 FEE AMOUNT DUE ' AMOUNT REMITTED CK RECEIVED BY DATE 'PEFIMIT"NO. INFO CASH +EH 13-24 IREV.101835 EH 14-26 'I - `�