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^. '� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH .DISTRIET i 1601 E. HAZE i ON AVE., STOCKTON, �CA COPY Telephone (209)-466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) rein described. This application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he m,iie 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 A A l 31�OcaHealth District. �i ©f7j t(lr t City '/) Lot Size ✓' d PM "":Job Address JOE I_ r r lq.3 7 /7CIC/I I/�Q/'S'a VLA� Phone -0 's Name _ �m /^ /�J I,q e / Address 7 Owner s. ,• A �– 0100/ Phone 122'7 Contractor QSS 4-S0� Address License No- y �— TYPE OF WELL/PUMP: NEW WELL :n WELL REPLACEMENT,;❑ I DESTRUCTION ❑ i – / SYSTEM REPAIR'10 OTHER ❑ ,, PUMP INSTALLATION I�d� DISTANCE TO NEAREST: SEPTIC TANK 7d� SEWER LINES `L. DISPOSAL FLD. PROP. LINE FOUNDATION 1040t AGRICULTURE WELL OTHER WELL " PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i' Open Bottom ❑ Manteca - Dia. of WellExcavation Dia. of Well Casing r in Specifications E Type of Cas �DomesLTc/Private ❑ Gravel Pack ❑ Tracy :� YP 9 [I Public F1 /her C1 Delta s* Depth of Grout Seal Type of Grout I 'I Irrigation Qr�_Approx, Depth I I Eastern Surface al Installed by Gd s " Repair Work Done ❑ Type of Pump ' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ! Q TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 F,'r AIWADDITION 1.1 DESTRUCTION 1 1:1(No septic system permitted if public sewer is Q }I (available within 200 feet.) Installation wills Residence Commercia�_ct Other 3i y Number of Erving units: umber of bedrooms , _ Character of soil to a depth of 3 feet: R 'i. r a le depth SEPTIC TANK ❑ Type/Mfg Capacity f1 l No. Compartments PKG.` TREATMENT PLT. ❑ I. Method of Disposal Distance to nearest: ' Well Foun Property Line LEACHING LINE ❑ No. S Le iinesk. '� fl Total leng e FILTER BED: ❑ ante to nearest: 'Well, Foundation 1;Property Line .k SEEPAGE PI lA Depth Size' Number 1' SUMP ❑ Distance to nearest: Well1 Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will A done in accordance+'with San Joaquin county ordinances', state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Homo owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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,I shall employ persons subject to workman's compensa- tion laws of California." ! k4 The applicant must ca for all required inspect ns. Complete drawing on reverse side. i,r :cz.G Signed Title: � Date: FOR DEPARTMENT USE ONLY Application Accepted by . Date I� 2��"' Area cows Wy Pit ar Grout Inspection by Dais Final.lnspeetion by Date I loco Additional Comments: �``~ r _ ❑ Stk 466-6781 ❑ Lodi 369-3621 - [IManteca 823-71 ❑ Tracy',]835 Applicant- Return all copies to: Environmental Health Pert/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED N. RECEIVED By DATE PERMIT•NO. INFO p l +.EH 13-24 IREv.1/"51 EH U-28 I� ,