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_ ..... .,.. � .. ... ... ..i � .'(h•.r S'�'T.� - ... .. :�� T.'C"1`•:°%vl.':1�f k'a•.rNSIvT,Y P.`]a^::. APPLICATION FOR PE. 41T SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 5V9©�� Application is hoteby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TNs 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 A9dress � � ' City � Lot Size PM J Owner's Name p( _ Address V Phone 41 Contractor 3Co r ✓- License No. hone/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _- FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PR09LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications k FI Public n Other R Delta Depth of Grout Seal Type of Grout 1 I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by e t Repair Work Done ❑ Type of Pump H.P. State Work Done_ U - j Well Destruction ❑ Well Diameter Sealing Material(top 501 -- r Depth Filler Material 1 Blow 501 TYPE OF SEPTIC WORK: NEN:INSTALLATION I I RI-PAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is i availab6i within 200 feet.). 1 Installation will serve: Residence_ Commercial_ Other_ 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 1} Distance to nearest: Well Foundation Property Line_ i LEACHING LINE No. & Length of lines /, Tgtal length/size FILTER RED ❑ Distance to nearest: Well.� Foundation 167-' Property Line A527 SEEPAGE PITS I I Depth Size Number ` SUMPS CI Distance to nearest: Well FoundationProperty Line _ DISPOSAL PONDS ❑ t I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state taws, 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 thiss 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 followi :"I certify that in the performance of the work for which this pormit is issued,I shall employ persons subject to workman's convents tion laws of Calif rn A The applica s call for requir ectl to drawing on arse side. _ Q SiCned X Title: K, ^ /' /!R/DEPARTMENT USE ONLY Application Accepted by f/-J`L f Date Area Pit or Grout lnsp9ction by - aD .o Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 G Manteca 823-7104 ❑ Tracy 835-6385 T { Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hszelton Ave., P.O. Bax 2009, Stk., CA 95201 y k CK FEE r INFO AMOUNT DUE AMOUNT REMITTED CASH RECFIVED BY DATE PERMIT'NO. r I i ..EH 13-24 IREV.IlA41 "I`,� EH itQa �"iJ / s