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r APPLICATION FQR PERMIT' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466:6781 PERMIT EXPIRES 1 YEAR FROWDATE ISSUED (Complete in Triplicate) j Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs application is t made In compliance with San Joaquin County Ordinance No.849 for sewage or No. 1882 for well/pump and the Rules end Regulations of the San Joaquin j Local Health District. r y Job Address f '/1 L" p - .�(}Cf� Ci:y _ Let Size PM Owner's llama 4'�`.. iris j- —j.L�ess — 3,1,aj Phone _ Contractor's Name � �� u(i G No. 7 - Phone ? e WZ TYPE OF WELL/PUMP: z NEW WELL ❑ WELL REPLACEMENT❑ /� DESTRUCTION C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ "'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE d FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ LWustrial ❑ Open Bonom ❑ Manteca Dia. of Well Encovatton Dia. of Wil Casing ❑ Oortaabc/Private ❑ Gravel Pack ❑Tracy Type of Starting Specifications j ❑ Public C Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---4ppros. Depth ❑ Eastern Surface Seal Installed by Repair Work Dona C Type of Pump H.P. $late Work Done O Well Destruction ❑ Well Diameter Sealing Material(top 50' 1t Depth Filler Material(Belo .>D') _ I TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION ❑ (No septic system Permitted if public sewer is available within 200 feet.) ' Insulation will serve: Residence_ Commercial_ Other_ 1 Number of living unitt:_ Number of bedrooms F Character of soil to a depth o1 3 feet: Water table depth �. SEPTIC TANK - ❑ Type/Mfg Capacity_ No. Compartments n PKG. TREATMENT PLT.❑� Method of Disposal Distance to nearest: Well Foundation _ Prooerry Line i LEACHING LINE No. b Length of lines j Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation_ Property Lino T 3 SEEPAGE PITS ❑ Depth Size n da i Number } SUMP ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C 1 I hereby certify that I nave prepared this application and that the work will be done in accordancg with San Joaquin county ordinances, state laws,and i rubs and regulations of the Sen Joaquin Local Health District. Home uwrar or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shefl not employ any narson in such manner as to become subject to workman's compensation laws of California:'Contracto/s hiring or subcontracting signature certifies the following:"I comfy that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws et California." The applicant must Ti for allregw/�(y�mspec,ions. Care drawing on r Tse side. t— S' nod x /tom' ' Title: C-'/(�7 Date: — _ FOR DEPARTMENT USE ONLY c! AWfication Accepted by \� 1 Date S ��1� O`o Ara L Ph or Grout Inspection by Date Final Inspection by 12 L/��'/�J%l':4 Daa ddnionsl Commend:J� Stk 486-6781 CLodi 303821 ❑ Mantace 821-7104 C TrAcv 8356385 Applicant Return all topica to: Environmental Heahh Permit/Services 1501 E. Hazelton Ave_ P.O. Box 2006, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K s RECE.-.2D 6Y DATE PERMIi'NO. INFO (( CASH .FH pal IREy.I010i C,_Y�n� �•�:/ a\ , �--L -/Illy fill 14ID r y