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� ul-- 2 — APPLICATION FOR PERMIT ®® �'�� ✓ a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,,,STOCKTON, CA. Telephone (200) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. I N� f Job Address N City n 'f—� Lot Size " PM d Owner's Name dress _moi�fDo X .�.ik _ Phone Contractor Address License No. 8�✓Phon � TYPE OF WELL IPUMP: NEW_WELL ElWELL REPLACEMENT E] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O DISTANCE`TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE # I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r !, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSr f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f % " ` ' Dia. of Well Casing } Rti,e - < :. Specifications ❑ Domesnc/Private 1 ❑ Gravel Pack., L3 Tracy Type of Casing �- pe O Public j j ❑ Others ` �t }�❑ e .A . "Dep hrof;Grout Seal 4 \`t f J Typo of Grout ❑ Irrigation t --Approx. Depth ❑,Eastern ---Surface-Seal-Installed-by, `— Repo Work Done ❑ Type of Pump H.P. tate Work Done. Weli)estruction I❑ Well Diameter Sealing Material (top 501 Depth Filler Material (B low 50') TYPE,OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION'❑ (No septic system permitted if public sewer is t/' f i available within 200 feet.) 'Installation will serve: Re once' Commercial_ ther Numbedof living units: - Number of bedr s Character of soil to a,depth of 3 feet: i Wa a table depth SEPTIC TANK ;C7 Type/Mfg Capacity a No Compartments I PXG(TREATMENT PLT. ❑ e hod of Disposal - 4 1 Distance to nearest: Well Foundation ._. Property Line LtACHING*,LINE ! No. � Length of lines 4069_. `�- r — o�l length/size FILTER BED ❑ Distance to nearest: Well /41:7 Foundations Property Line ~ t SEEPAGE PITS (depth .�.]^ Size -� !� Number SUMPS ; ❑ Distance to nearest: Well .��— Foundation PropertyLine DISPOSAL:PONDS ` ❑ + (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 truies 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 l 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 tali for all required inspections. Complete drawing on reverse side. Signed X _ Title: Date: `i �� FOR OEP_ARTMENT USE_ONLY Application Accepted by Date Area —�� " Area d rr 2-17C Pit or Grout Inspection - Date,�7—1?�� Final Inspection by Date �/•A k Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 FEE AMOUNT DUE AMOUNT REMITTEDC RECEIVED BY DATE PERMIT`NO. INFO + EHt&24IREV.}/B51 - 7<> e EH 14-26 ( n