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APPLICATION FOR PERMIT 4 N JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA raj Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0t (Complete in Triplicate) u Appli Qj to the San Joaquin Local Health District for a permit to construct and/or install the work herein escril ed ms application ad,Nn�} Narac�with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welltpump and the Rules and Regulations of the,Saiil l�dq iA� Local 4alth District. Job Address J-Z� -Tr IS o City�rQ L Lot Size PM Owner's Name A Address 44kaq4a Phon js 'Z Contractor 1'L Y _..—Address �� 'r �� 1 License No. 6 Phone 6p6_931-` TYPE OF WELL/PUMP: NEW.-WELLJK, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Or .lf)j19fY �Cet.� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i0 Dia. of Well Casing ❑ Domestic/Private Gravel Pack Tracy Type of Casing �.- Specifications 4- M Public {1 Other FIDelta Depth of Grout Seal N� Type of Grout .a Ii Iu 17 I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by - i Repair Work Done ❑ Type of Pump Al H.P. State Work Done, F' n[ Well_Destruction•r ❑ Well Diameter Sealing Seating Material Itop 50') A�►t�ly1►► r�V� Depth_W'F+ Filler Material (Below 50'1 1 TYPE OF SEPTIC WORK: W INSTALLATION t'I REPAIR/ADDITION { I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other i Number of living units: Number of oms Character of soil to a depth of 3 feet: Ater table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:' Well Foun Property Line I LEACHING LINE ❑ No. & Length of lines I length/size FILTER BED ❑ Distance to nearest: Foundation erty Line SEEPAGE PITS t I Depth Size _ Number SUMPS ill ' ance 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 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."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 Califo 'a." SAN )OAQ4JIN LOCAL HEALTH i�15TR! The applicant m st II for all e d ins tions. Complete drawing on reverse side. VIPON�IMENTPL 1JEALT€-I DIVISION p Signed X Title: �f�y s, P, eDaek_. - . Application Accepted by FOR DEPARTMENT USE ONLY Date t!�J z�,� ��J_?9 Area Pit or Grout Inspection by Date_. � Final Inspection by /-/spm Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 85201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT N0. INFO + EH 13-24(REV,1/95) 3 s. G";:7 � EH 14-26 yam,