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x7 .' APPLICATION.FOR PERMIT SAN JOAaUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. J Job Address �`�4' City Lot Size' _ Q Owner's Name, J ` p+5�' '57Address '' r A' 1 Phone ContractamJZ,Q,12y 5 511`-�'�iiddress !!:�/-Z r5� rs License Nom �- Phone TYPE OF WELLIPUMP: NEW WELLWELL REPLACEMEN DESTRUCTION 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK hV1 SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION4?3 f AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L� 0� Industrial pen Bottom C1Manteca Dia,,pf Well Excavatio Dia. of Well Casing "Mastic/ ❑ Gravel Pack ❑Tracy Type of Casing Specifications p �_ ('I Public ❑ Other Cl Delta Depth of Grout Seala� Type of Grout910—!Approx. J✓- r __ I�Irrigation 910—!Approx. Depth I I Eastern 'Surface Seal installed by 7 Repair Work Done Ll Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I,I DESTRUCTION E 1 INo septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms r Character of soil to a dept of 3 Water table depth SEPTIC TANK ❑ Type/Mig Capacity' Na. Compartments PKG. TREATMENT PLT.❑ Method of{)isposa! Distance to nearest: Well- Founda i Property Line LEACHING LINE ❑ No. & Len kr- f nr es Total lengthlsize FILTER BED ❑ D ce to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS D 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 District. 77) 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, l shall not employ any person in such 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." y- " The applicant must call for all required i pections. Complete drawing on revere side. a �} Signed X Title: �.!orw _. Date: FOR DEPARTMENT USE ONLY Application Accepted by _ P>\r - Date~J '"''Z Area_ -- - Pit or Grout Inspection by Date �y" Final Inspection by r � Date � j.__ Additional Comments: :0 Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/S'ervicBS 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952,%-- ;,__ 520 C,6. - L FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO SHEH 13-24(REV.I/A5) [j �CA Err a-26 t�