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• APPLICATION FOR PERMIT • i �y�- SAN JOAQUIN LOCAL HEALTH DISTRICT f .{ l� 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 3 isdC� (Complete in Triplicate) 'WIRQNJVENTAL HEAI Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hgrerR 1t �pR4J)(�s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/Dump and the Rules and R§Qu'IaYrons of the San Joaquin Local Health District. _r Job Address F�(a WuDw��yn/7 �Z5 ��5� +�li 7' City Lot Size PM u � w J c 4 v�-.A w� p W �U z S ! �c r b- -by— "l l 5 - 13 3d- PhoH 3 Owner's Name Addressne Contractor S IL'r v G �tldless ' License No. N y 6 G To Phone eD - "7- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Fl(j Wyi1 ta,yd,n PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W L'F AAb(ti,},1e DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a�`i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 443tr� durtw INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' e"l c CC Va v� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing /_`t r (�' CIDomestic/Private El Gravel Pack El Tracy Type of Casing Specifications k1i") g M Public 171 Other 71 Delta Depth of Grout Seal Type of Grout_ / _ I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Q(� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) I I� Installation will serve: Residence_ Commercial_ Other V� Number of living units: _ Number of bedrooms �M1 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 nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size S FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 Health Driltrict. 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 become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in a performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion law a ornia." Thea plicam m If re r inspections. C m late drawing o arse P 9 Signed _ Title: ,(� 3 Q Date: FOR DE TMEN NLY Application Accepted by Date </O �O Area Pit or Grout Inspection by Date Final Inspection by 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 CK 0 CASH RECEIVED,4Y nDATEt PERMIT' EH 13-211REV.1/x sl EH 1/-2e NO. t. 7��j tJ+