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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT DEC 4 9939 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 E`d''1R'ZN',W1=FATAL HEATH PERMIT EXPIRES I YEAR FROM DATE ISSUED FLEMMII USERMES (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 d Re do p t SagJoaquin r Local Health District. k` V11 — Job Address 9 4A�4/M Al r- JIJCtd city •�-6 / '.L Lot Size PM Owner's Name zo,.,,Q //�� A. Address eO .dO.1/'/� s/0.^//..i � Phone 00? J jrw Contractor /Al _%Z.ftA Address d License No.fi'3�SSf 'Phone �3P'a�L t. TYPE OF WELL/PUMP: NEW WELL IIS WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 09184.14' y A Jll c..l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 'elf FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation b 1/O Dia. of Well Casing ❑ Domestic/Private 04 Gravel Pack ❑ Tracy Type of Casing Ave, Specifications ff M Public ❑ Other fill Delta Depth of Grout Seal 01V 5.1 /Type of Grout�✓J'rz" C 1 1 Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installedh, lA/� _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 ,(I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other e('( 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 X11 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size q FILTER BED ❑ Distance to nearest: Well Foundation Property Line of SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ TyI 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 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: "1 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 lrre(pi.red i spections. Complete drawing on reverse side. Signed Title: [y Z Date: 1� R TMENT USE ONLY / Application Accepted by Date rete Pit or Grout Inspection by JJ //Date%] a Final Inspection b Date v Additional Comments: ✓Ll�m ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7100 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEgMOUNT DUE AMOUNT REMITTED NFO RECEIVED BY DATE PERMIT NO. H • EH 1423 IREV.vxsr Q�