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i i APPLICATION FOR PERMIT SAN JOAQ:UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON,.CA p/SA 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 applicatlon is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1861 far well/pump and the Rules and<Regulations,of the San Joaquin Local Health District., .h . ': .,.-f :: r -�-'rl - f,.,:. t�t 7 _ y ti... Lot _ f� -.-_ PM. Job Address 0 CitLt Si 1 - - - ..... _ . 7. Owner's Name l fr ��` Address.T - Phone [9� Contractor's Name License No. Phone y �� TYPE OF WELL/,PUMP: NEW WELL NWELLREPLACEMENT ❑ DESTRUCTION ❑ t ""'—PIl1VIP'iNSTA-L t'ATI0N-0 ` =SYSTE1d9'-fiEPAIR-❑ OTHER'❑""""'l'^� o ;ZG�"� SEWER LINES DISPOSAL FLD.Is� PROP. LINE DISTANCE T04NEAREST: SEPTIC TANK -' - __ ' FOUNDATION;—'AGRICULTURE INELI `""` OTiiERVELL PITS?SUMPS INTENDED USE TYPE OF L PROBLEM AREA CONSTRUCTION SPECIFICATION El Industrial ?<Cron.Bottom El Manteca Dia. of Well Excavation Dia. of W II Casing Domestic/Private Gravel Pack ❑ Tracy r Type of Casing Specifications�� q I O"`!t`re"r' r '❑ Delta Depth.of Grout Seal �� - Type of Gout ` ❑ Irrigation ---Approx. Depth ❑ Eastern ""Surface Seal Installed by j s Repair Work Dane ElType of Pump H.P. � State Work,Don. Well Destruction ❑ Well Diameter Sealing Material (top 501x ' Filler Material (Below 501 r f O Depth !j lWiE_ QF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LDDESTRUCTION ❑ (No septic system permitted if public sewer is � available within 200 feet.) ^` InstallationResidence— Commercial— Other— Number ther Number of living units: 'i Number of bedrooms Character of soil to a depth'114,k% _o-o Water table depth SEPTIC TANK' ❑ Type/Mf7ne Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method o#.DisposalDistance t: Well undation Property Line ' LEACHINGi LINE ❑ No. & Length df lines 6 r tal length/size i FILTER BED I ❑ Distance to nea%rest: Well Foundaiion operty Line ' I! SEEPAGE PITS ❑ Depth Size y "i> Number ;�.•, �, "f? SUMPS _t _ ID Distance to nearest: Wellroper T Foundation Pty Line . ..3 _ ` DISPOSAL PONDS © - hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqu'i�n county ordinances, state Iaws, rules and regulations of the San Joaquin Local-Health-DlstricV Home owner or licensed agent's signature certifies the following: 'il certify that in the performance of the work for which this permit is issued, I shall not employ any peison in such manner as to become subject to workman's compensation laws of California." Contractor's 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 Californi ." The applicant mu c for all required in ctians plate drawing on reverse side. Signed r Title: n Date: 8 0 Y FOR DEPARTMENT USE ONLY W Y o 3:=$ a Application Accepted by Date Area Pit or rout Date spection by Date Final Inspection by x , Additional Comments. i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82:0104 El Tracy 835-6385 r - Applicant- Return all copies to: Environmental Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2008, Stk.;CA 95201, FEE AMOUNT DUE AMOUNT REMITTED y CASHJ� RECEIVED'8; DATE PERNpT"NO. INFO +EH 1324(REV.101831 EH 14-28 LA:3