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s - ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ." (Complete in Triplicate) 4, I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thfs 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 Dirstrict. { /1�C/� , � Job Address � � � � � City C Lot Size "� PM r _ / i .. � Via. . Owner's Name I!Y 11 x �/ "Z Address - Phone ��GZlntr Efo�� Address hi D l kxo X X"b License N ��__Phone 3/- 3.2/0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR�1( OTHER ❑ ___,_DISTAN CE_TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION "u"""AGRICUL'TURE"IVEL'Lti- A "'OTHER WELL -- -,PITS/.SUMPS INTENDED USE TYPE OF WELL " PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ] i Domestic/Private- ❑ Gravel Pack ❑ Tracy Type of Casing Specifications pecifications ❑ Other EJ Depth of Grout Seal Type of Grout ❑ irrigation _Approx. Depth F] Eastern Surface Seal Installed by it Repair Work Done ❑ Type of Pump H.P. State Work Don XTP- AS/ (* `/¢ Ovj ! Well Destruction ❑ Well Diameter Sealing Material (top 50'1 G^47oLWb• F/L Q 1 T RAt Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ll DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence Commercial_ Other l Number of living, tin s:'---Number-of bedrooms Character of soil to a depth of 3 feet: j Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line - � F LEACHING LINE E37tv No. & Length of lines Total length/size ` FILTER BED ❑ Distance-to nearest: WellFoundation I Property Line SEEPAGE PITS ❑ Depth Size Number f ' SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS _Elf= -- Property-Line I hereby certify that I have prepared this application and that the work will be done in accordance with Sah-Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 I ' 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 's compenure tion laws of California." ,'I'shall employpersons subject to workman The applicant or al a uired inspections. Complete drawing o re erse sid yf K I /j� �'� I Signed" Title: Q'Q N Je f#C D!K {{ Date: OR DEPAR MENT USE ONLY T " 4 [`J -• 71 Application Accepted by A 4: Date Pit"or Grout-Inspection-by- —" "-.�.-- ' ¢ q Pe Y- Date-- - --- mal""Ins ection by M+ pate" ! s Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy.83Fr6385 Applicant- Return all copies to: Environmental Health Permit/Services_1601 E. HazeFlton Ave., P`.0. Box 2009,-Stk.;CX95M 4 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE . MPERMIT'NO.+ EH W24[REV. �EH 14-26