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f APPLICATION FOR PERMIT SAN JOAQUINLOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin LocalHealthDistrict 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 Ryles and Regulations of the San Joaquin Local Health District. ° _. F 4'3 . - v ' Ss- Job Address' ��S 16 " � � ,' � Ci Lot�Size' Owner's Name A lY `/4 )e p/ Address "�T Phone / O� rN S Y�►AT�= S Address la 0 4 C O X lk icense No. Phone .3/-3A/O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack — ❑ Tracy- T s ype of Casing Specifications ❑ Public' ❑ Othar ❑ Delta Depth of Grout Seal °Type of Grout ❑ Irrigation ---Approx. DepthAJ ❑astern Surface Seal Installed by 11Repair Work Done Type of Pump ;J H.P. 1 State Work D F EX [STS 6 Well Destruction ❑ Well Diameter Sealing Material (top 50') (J / Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is p\ available within 200 feet.) S I Installation will serve: Residence_ Commercial I Other Number of living units: Number of bedrooms N Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ --- ----- �-m-- Method of Disposal Distance to nearest: Well 4�= Foundation Property Line I I _ 'A_ i LEACHING LINE ❑ , No.F& Length of lines A- N \.- - Total length/size FILTER BED EJu Distance to nearest: Well i, Foundation Property.Line I SEEPAGE PITS ❑ Depth Size 1! Number i L SUMPS ❑ Distance to nearest: Well i Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared-this-application-and--that the-work will be-done,in-accordance-with San'Joaquin coun"I'dieW—Cts,61 are`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`comp.ensation,laws:ofiCalifornia."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of tFie work for`which this'permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must ca or all required inspections. Complete drawing on r ve a sid Signed>L1®C:d Title: 4 TO Date: Q FOR DEPART ENT USE ONLY 1 f Application Accepted by Date Area Pit or Grout,Inspection by Date Final'Inspection by Date Additional Comments: LI 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 CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-No. t Ek 13.24(REV.1/$5) J1 �^ Eli,4-26 ...]