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br/ APPLICATION FOR PERMIT 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. w �(( -1' f;i opt-r-s 40 1 Job Address 7ctI `L�? PA � Y'Q[Gt -R" Cit'h/ -ot Size.13 AFre- PM / Owner's Name CcCt✓ mr4 -FYedQVICk AAdd. ►976 I-Ootb}-ard " gScm 6SQiH Phone 3`-0 Contractorpiu f� u t_WeAl Address T.� ��.J Rd� ,,IbGF,�L she No.5.2Phone TYPE OF WELL/PUMP: NEW WELL ❑_/ WELL REPLACEMENT 11r' DESTRUCTION AT PUMP INSTALLIONN (N SYSTEM REPAIR ❑ OTHER El �O DISTANCE TO NEAREST: SEPTIC TANK 150 SEWER LINES 50 DISPOSAL FLD.J_C� PROP. LINE FOUNDATION—O AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS „ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavaation_(O' Dia. of Well Casing I�Domestic/Private VGravel Pack ❑ Tracy Type of Casing T V G Specifications M Public 71 Other C1 Delia Depth of Grout Seal Ino, Type of Grout Cel+teKT I I Irrigation _Approx. DeQQpppptt'h--''�� it Eastern Surface Seal Installed by C Q(LVQ'tCY lr ((1 R� _ Repair Work Done ❑ Type of Pump H.P. a. State Work Done�CtnSt�( l9 MfW we- Well GWell Destruction 19' Well Diamn eter � Sealing Material (top 50') Depth A�r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 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 O 1 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 D13trict. 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accept y Date Area Pit or Grout Inspection by Date, Final Inspection by Date Additional Comments: 7r, or ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 035-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I INFO AMOUNT DFEEUE AMOUNT REMITTED CASH RECEIVED BY DATE MD ,t411 f5� �I' EN 132�IREV.rinsi �� [ c-f� iy.. �iM- y -i r EN t/-at (r,G-'1q A