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►� _ — APPLICATION FOR-"PERMIT J SAN JOAQUIN LOCAL HEALTH DISTRICT , d : 1601 E. HAZELTON AVE., STOCKTON, CA �- Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 r ty Lot Size PM r r Owner's Name ^� ass —��r✓t, Phone n Contracto Addressal N. License No.� Pho_ne /Lq TYPE OF WELL/PUMP: NEW WELL IV WELL REPLACEMENT ❑ DESTRUCTION ❑ t \ PUMP INSTALLATION- him SYSTEM REPAIR - " OTHER ❑ Q DISTANCE TO NEAREST: SEPTIC TANK L750 / SEWER LINES /-.- L/Q DISPOSAL FLQ'f ff PROP. LINE .2-5-D FOUNDATION AGRICULTURE WELL OTHER WELL.2 o'e/PITS/SUMPS' ` INTENDED USE TYPF,OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC �— / 4 ❑ Ind rat pan Bottom ❑ Manteca Dia. of Well Excavation . Dia. of 1Ne11 Casing_. omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing /j�� Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout SealType of Grout �t � ❑ Irrigation_ 2p�Approx. Depth E1 Eastern �urface Seal Installed by .._. RepaiYlhork Done, ❑ TYpe��af Pump H.P. State Work Done Well Destruction '"� O" Well oiameter Sealing Material (top 501" - r Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200-feet.l-r Installation will serve: Residence— Commercial— Other r 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 t r. 9 i Total length/size FILTER BED ❑ Distance to nearest: Well Foun'{'ga°tion Property line f�j> SEEPAGE PITS ❑ 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 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." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicantt call for all requi ed nspectiorls. Complete drawing on r rse side Signed X Title: 1 Date: ^' r FOR DEPARTMENT USE ONLY Application Accepted by Date Ara. t Pit or Grout Inspection by Date nel Inspection by Oat, Fi r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ...P�..E.R✓✓�111MIT'NO. /01�r EH 1321 11M1/fl51 (J ,/y- EH 1428 ! �/ / ��A'"�