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� e ` APPLICA TfON.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA `Teiephone 92091 466-67,91 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. q Job Address � l City Lot Size PM Owner's Name;y2W / .Sr�,ly1 � Address S v�Ti�h i ./� Phone 3 - t Contractor in + Address License No Phone TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT, ( _ DESTRUCTION ❑ ' PUMP INSTALLATION 13SYSTEM REPAIR'X MOTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK �2 SEWER LINES ;'� DISPOSAL_FLD.�_-PRO P. LINE -. . FOUNDATION Z AGRICULTURE WELL OTHER WELL != PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS p 1 ❑ Industrial I In Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 )fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public ❑ Other # ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation , --Approx. Depth ❑ Eastern Surface Seal Installed by --� Repair Work Done Type of Pump H.P.�� _ State Work Done f j Well Destruction ❑ Well Diameter Sealing Material {top 50'I i ,_ YA Depth Filler.Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INofseptic system,permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: }� Water table depth SEPTIC TANK ❑ Type/Mfg f '4 Capacity * No. Compartments PKG. TREATMENT PLT. ❑ i' _� 1 t Method_of Disposal Distance to nearest: Well Foundation Property Line �J LEACHING LINE .�. ❑ No. & Length of lines " �� - Total length/size s FILTER BED r t. ❑ -Distance to nearest: Well Foundation Property Line" 1 SEEPAGE PITS + ❑ Depth } Size Number I Y SUMPS .. .❑ . Distance to nearest: Well Foundation Prope'it 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 perforniance 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." The applicant m st c lal.for`all required inspections. Complete drawing on reverse side. c Signed X Title: pate + q FOR DEPARTMEN USE ONLY / Application Acceptedy Date Area d 3 _ Pit or Grout Inspection by r pa Final Inspection Additional Comments: ❑ Stk 466-6781 I❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA,95201 FEE INFO AMDUNT DUE AMOUNT REMITTED CASH RECEIVED BY' 4' DATE PERMIT N0. ; EEH H 13-24 MEV.t i a 51 �'s U V 4 .[5�0 / �- -S y r