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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) 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 f made in compliance with San Joaquin County Ordinance No.549 for sewage or No.,1862 for Local Health District. well/pump and the Rules and Regulations of the San Joaquin � Job Addressf^r` � 'n ill Lo S- a �, PM e ores c�tK o�� F3?�-/77 Owner's Name o Address I�" ✓ ,- _" Phone m g eku Contractor's Name 1+11 - License No. C Q � �}• T 1 TYPE OF WELL/PUMP; NEW WELL ❑ PFione' WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION t❑�INSYSTEM REPAIR ❑ i DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ " SEWER LINES ��— DISPOSAL FLD ' FOUNDATION �+ AGRICULTURE WELL PROP. LINE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL" ' • PROBLEM AREA CONSTRUCTION SPECIFICATIONS y , ❑ Industrial El Open Bottom ❑ Manteca ❑ Domestic/Private ❑ Gravel Pack """""Dia. of,Well Excavation 4❑ Trac ��Dia+•-of Wel! Casing ❑ Public + y Type of Casing 4-r S ❑ Other 11 Delta pecifications Depth of Grout Seal j f ❑ irrigation ,,%\• Type.of Grout .i �Approx. Depth; ❑ Eastern Surface Seal Installed by �2�- Repair Work Done ❑ Type of Pump A -- :w H.P. i State Work Dane Well Destruction ❑ Well Diameter Sea ^ + ling Material(top 50') i .1 Depth r t Filler Material {Below 501 I TYPE OFrSEP_TIC WORK: NEIN INSTALLATION REPAIR/ADDITION C7 DESTRUCTION ❑ iNo septic system permitted if public sewer is 1 available within 200 feet.) installation will serve: Residence-E Commercial_ Other CE.+�" , Number of living units: Number of bedrooms ,_ { XCharacter of soil to a depth of 3 feet: - - u yy� �• , SEPTIC TANK 1�. Type%Mfg Water table depth PKG. TREATMENT PLT. ❑ �•. �� Capacity-if- 10 No. Compartments ....r t Distance to nearest: Well w�,. Method of Disposal ; Foundation "" Property Line LEACHING LINE 4' No.& JF of lines - (� "fes FILTER BED ❑ Distance to'nearest:ti # Wali, � Total^length/size Foundation �• Property Line SEEPAGE PITS ❑ Depth Size x ` SUMPS DistanceNumber to nearest: Well ASO ¢ Foundationy- DISPOSAL PONDS ❑ — -= Property I f hereby certify that f 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 o become subject to workman's compensation laws of California.';Contractor hiring oPsufrcontract ngrmit is issued, lsignashallture employ any person in such manner as t certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall em to P tion laws of Calif rnia.,, P y persons subject to workman's compensa- tion applicant st all for all required inspections. Complete drawing on reverse all Signed { " Title: Date: C?/ FOR DEPARTMENT USE ONLY Application Accepted �� Area r f Q�a Pit or Grout lnspecti y r�J Date Date Final Inspection by -30� Additional Comments: Date ❑ Stk 466-6781 ❑ Lodi 369-35 + 4 i ❑ Manteca 823-7104 ❑ Tracy 835-6385 ! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2D09, Stk:;CA 9520} t �- €11 ' S - INFO- ^AMOUNT pIJE AMO firflT 1 w-- -CCK -RE _IV D�Y 4 k CASH- DATE ERMiT•`N(5"�'""�`"'-""""—� { I k Y —7� k� ++ r.^►ww....r�,.�—�-...`�`_��1-.''�� .a �..+-..wYrw...,..iVv .�.. �'cnwws�.sts.