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%{} '` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IE (Complete in Triplicate) 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin r Local Health District. li JO Job Address t7�o�iD� �" /re7��ie[,��c!' CityLot Size r PM Owner's Name f L� t �- Address -2pal,fla 1AA1 C A Phone n,t - Contractor 1 ►1 l • Address P0' -7"" �d l License No. 3 —27-C_ Phone -5105 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/ „ ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public I� ❑ 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 Well Destruction ❑ Well Diameter Sealing Material-(top 501 Depth Filler Material (Below 501 TYPE OE.SEPTIC WORK:__NEW INSTALLATION .--REPAIR/ADDITION.❑ ^DESTRUCTION El. (No.septic.system_permitted if-public sewer is i available within 200 feet.) Installation will serve:—Residence zJCommercial="'0'ther— -T Number of living units: Nuinberof-bedrooms Character of soil to"a depth-of-3 feet nn - ,,//__,�, Water table depth SEPTIC TANK ❑ Type/Mfg _ &:xz- Capacity No. Compartments -PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 5a Foundation /,0 Property Line LEACHING LINENo. & Length of lines Q / Total length/size f r S� -� FILTER BED � ❑ Distance to nearest: Well Sa� Foundation �� / Property Line SEEPAGE PITS Depth 75 / Size Number 3 SUMPSLlDistance to nearest: Well I do / Foundation d / Property Line -5 +F DISPOSAL PONDS ❑ ¢` t w� 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. Horne 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 a employ any person insuch 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." l } The applicant must call fo II required inspections. Complete drawing on reverse side. �. �. l Signed �-�-� Title:._.. Date: f FOR DEPARTMENT USE ONLY Application Accepted°b Date Area ' Ph.or Grout Inspectit by Datfl— Final Inspection by Date 4 Additional Comments. ❑ Stk 466-6761 ;''-❑ 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 ! AMOUNT DUE AMOUNT REMITTED O.RECEIVED BY DATE PERMIVN INFO i n C"n 4 4 + EH 13-24 MEV,1/851 � 14_Sq EH 14-28