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r -�...� 46. APPL1CAT[ON FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA plyTelephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City A&I it- Lot Size PM Owner's Nam !"eL 3/ a _-,•••�Lft: g_JQ2�_ Address c hone Contractor G AddressP�!!�it� UQ(A NO— License No. d Phone 42 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTALLATION ❑ SYSTEM REPAIRk 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 Dia. of Well Excavation Dia. of Well Casing ,Domestic/Private ❑ Gravel Pack CI Tracy Type of Casing Specifications FI Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation _Approx. Depth i I Eastern St ca Seal Installed by Repair Work Done Type of Pump ��p,� H.P. State Work Done c- Well Destruction ❑ Well Diameter Sealing Material Stop 50't Depth Filler Material (Below 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION t 3 DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.),Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Y Method of Disposal Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel! 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 count`y'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 taws 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 compo a- tion laws of California." The ap call for all require pecti s. Co ote drawing on reverse side. Signed X Title: 5 Date: FOR DEPARTMENT USE ONLY 1 Application Acceptedby ��10 _ Date _72-r Area Pit or Grout Inspection by Date Final Inspection by Date 1/ 7� Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Mantes 823-7104 0 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 CASH RECEIVED BY DATE PERMIT•NO. • EH 13.24 1pEV.tin 5) EH 14.28 I r