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APPLICATION FOR PERMIT ✓i . ' W . SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 f �. ERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) ' :` ` ' ' � 1,..�• . ..� •t: ... 5• •• i t, Apofi- tion hereby`m`ada to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in com liance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin f .rl_ocal Health District, . 'n Da, u N + n• _ "� `� - . Jab Address ' cf City�L¢i;(C_p- LLot Size__�_ �._ PM fit Owner's Name )r GAS C� Yr oG�nl Address y a -5-o.. A-t- ` :l�Je Phone -C)16 3 Contractor Address license No. Phone TYPE OF WELL/PUMP: - NEW WELL G 'WELL REPLACEMENT C DESTRUCTION PUMP INSTALLATIO /C SYSTEM REPAIR El OTHER 11 DISTANCE TO NEAREST: SEPTIC TANK `ef SEWER LINES ___ DISPOSAL FLD. PROP. LINE FOUNDATION# AGRICULTURE WELL OTHER WELL _. _._ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d I il Industrial ❑ Open Bottom C Manteca pia. of Well Excavation Die?of Well Casing 7 Domestic/Private ❑ Gravel Pack r Tracy Type of Casing _ Specifications J Public ❑ Other L Delta Depth of Grout Seal Type of Grout l ❑ irrigation _Approx. Depth f' Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump e� H.P. State Work Doneelk Well Destruction - FJ Well DiameterSealing Material trop 50 . ) r Depth_-_ Filler Material iBelow 501 , TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITION _J DESTRUCTION . fNo septic system permitted if public sewer is ailabie within 200 feet.) U r Installation will serve: Residence_ 'Commercial_ Other A Number of living units: Number of bedrooms i r Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK G Type/Mfg r^ - Capacity No. Compartments PKG. TREATMENT PLT.❑ , Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE -I No. & Length of lines _-.._° ' r!" { Tata) iengthlsizel— FILTER BED ❑ Distance to nearest: Well t Foundation _ Property Line SEEPAGE PITS ❑ Depth Size f Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin canty ordinances;state laws, and'k:. 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 a 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 appI' - ust call for qui r inspe ctions. Complete drawing on reverse side. Signed v , Title: I�(Jl� Date: FOR DEPARTMENT USE ONLY r Application Accepted by _._ __ Date Area L �- ----�- 7i fit or Grout Inspection by /� _ D//ate _ Final Inspection by <- ->.' � Date � Additional Comments: 61 a� �F� t' = o-^ - ❑ Stk 468-6781 ❑ Lodi 369.3621 ❑ anteca 823-7104 D Tracy 835- Applicant- Return all copies til: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE { r: INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE f ERMIT N0. EH 13-24{EH 1428 iREV.1/851 S♦ d�.. • �� Y()�