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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ��l/ NOV fi Q 1�$9 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insgl��l!wlllpwQ 4AWIT"EW.EAL'fMication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and th4:qZrtml 7! JM"J a San Joaquin Local Health District. , Job Address �-` City �C'_�-[� a " Lot Size PM � r Owner's Name L! ~ AddressPhone '{,�1 _ Contractor'y. � ��'"� --- Address Z40—� License NV ��73 Phon6 4 2'S TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑'J'. SYSTEM REPAIR OTHER Q DISTANCE TO NEAREST: SEPTIC TANK `' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q"Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (-I Public ❑ Other LlDelta Depth of Grout Seal Type of Grout ' I I Irrigation --Approx. D h l l Eastern t Surface Seal Installed by j Repair Work Done L-J' Type of Pump H.P. f' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50').- Depth 0').Depth Filler Material (Bel'ow,50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I it DESTRUCTION I I (No septic system permitted if public sewer is � f �' available within 200 feet.E Installation will serve: Residence— Commercial— Other I j r \ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ~—'- -- - ----- - - - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to neare t: Well Foundation Property Line LEACHING LINE ❑ No. & Length of Ines Total length/size FILTER BED EJDistance to neareR.. Well Foundation Property Line SEEPAGE PITS I 1 Depth )+ Size Number i SUMPS Ll 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 rules and regulations of the San Joaquin Local kealth-Diltrict. Home owner ornsed agent's signature'certif'res`the following: "I certify that in the performance of the work for which this permit is issued, I shall not employany_perso.n m_such'manoer as_'to-ib -to wofkman: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 applican u t call for all required inspections, Complete drawing on rev-arse sidle. Signed X itle: /2^' L� Date: �y' ,�S FOR DEPARTMENT USE ONLY �+ �' Application Accepted by % "_ Date �7' Area �16, C7 Pit or Grout Inspection by Date Final inspection bv�� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. E+`1 13-24(REV.;/ns) EH 14-214-28 !Tt �� 1Uti3 �X773 7 1 ,