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t� • • 1 APPLICATION FOR PERMIT I y' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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 forwell/pump and the Rules and Regulations of the San Joaquin Local Health District. w f, , ,N}.17 �j -{RPI ,,��1��z�� Job Address ALS' SAI � � '� City '-'S ' `•" Lot SizeSRUc-E� PM Owners Name t/g0�aciiis) h 1�''{/1n 17 Phone Contraclor04-V mak Address License No.3CO>� Phone 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR%& OTHER ❑ g DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /\ DISPOSAL FLO. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -__ Dia. of Well Casing c ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications f-I Public ❑ Other �, 71 Delta Depth of Giuut Seal Type of Grout ,��,(1�rrigation —Approx. Depth\l I Eastern Surface Seal Installed by - IES-p-..;;'&T .TRT. -Type..' - _- —State .-- Repair WdikDone ❑ of Pump '(Z7j IlJG H.P `-"eD-�- ��Stata Work one_ 4We11_Destmction ❑ Well Diameter Sealing Material Itop 501 t Filler Material (Below 501 - K v t�.t( TyP,.&OOP.SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION4 1 (No septic system permuted it pu6Lc sewer is #� f, 1-' aVailable within 200 lead N \.; 1 pit fjbfl will serve: Residence_ Commercial _ Other ` pprye r � iNumbe'r'dfltiving units: Number of bedrooms i 3' - Character of soil to a depth of 3 feet: ' Water table depth Capacity No. Compartments SEPTIC TANK C3 Type/Mfg PKG. TREATMENT PLT.❑ j .z . °' Method of Disposal Distance to-nearest: . Well - Foundation Property Line I V t o LEACHING LINE ❑ No. 8 Length of likes Total length/size � FILTER BED ❑ Distance to nearest: Well Foundation ! Property Line SEEPAGE PITS I I Depth Size _. Number SUMPS'. ; "1' ❑ Distance to nearest: Well Foundation Property Line }' DISPOSAL PONDS ❑ ,t 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 Dihtrict. - 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."Contractors hiring or subcontracting 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 applicaii;t ust call for all requiEedd inspections. Complete drawing o,,,n//rreveerse. side., �z t�-y�� y . Signe Title: 1= ... szG/S/�L Date: �OR DEPARTMENT USE ONLY Application Accepted by`s�� h LC., � Date Area �L�� Pit or Grout Inspection by Date Final Inspection by Date" Additional Comments: ❑ Stk 488-6781 ❑ Lodi 3643621 ❑ Manteca 823-7106 ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT'DUE vAMOUNT REMITTED CK �: RECEIVED BY DATE PERMIT NO. INFO CASH wEH I}N IREV.Irx51 3S ,D� 3S',Ob 3? 3 3/ � Z EH u.ae f.