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- y ++!l!l -n f . APPLICATION ,FOR PERMIT k SAN JOAQUIN.LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �4 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/OT 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 �I�.7 �ri �.�. / r!tf �C3� Cit i ' G Lot Size PM / r J �f Owner's Name a •; /Address :7�1 6 A)• e(�' �S)d Phone Contract* utg2- c' 00 Address_� ��( 7�� '�"`r' License NoZ—:42--�)(O Phon6� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Tracy Type of Casing Specifications f ❑ Public L) 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 _ x Well Destruction ❑ Well Diameter Sealing Material (top 501 kjJ DepthI r Material (Belo" TYPE OF SEPTIC'WORK: NEW INSTALLATION ❑ REPAIR�ADDITION Ur 'DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) ' Installation will serve: Residence ;Commercial Other 111 Number of living units: Number of bedroorlQs t 'Character of soil to a depth of 3 feer '.�:i + .,L-- t: Water table depth lee F11 SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments , PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation Property Line r Fj LEACHING LINE ❑ No. & Length of lines Total lengthlsize i FILTER BED ❑ Distance to nearest: Well Foundation Property Line 04 j fit SEEPAGE PITS 51"Depth e-q Size Number SUMPS 0 Distance to nearest: Well Foundation /1S 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 Heakh 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 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." I The applicant tali for all req 'red inspections. Complete drawing on reverse side. -- Signed X �ust ( .%'�= Title: �/ �._ Date: y FOR DEPARTMENT USE ONLY Application Accepted by Date Area k Pir r Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 F. 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 PERM17'NO. + EH 13-24(REV.t i a 5) EH 1428 � F -