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A+. -Yrl .ia �.;- 1•rte'///�rt - APPLICATION FOR PERMIT tz SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '!'YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Disttict for a permit to construct and/or install the work herein described. This application is t 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. �t Job Addre r " _� _ "" _ City Ot Size PM wner's a Address Y 9 Contr Address G ense'f+l`o � Phone c � Ilk TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERoi _W psermL�`d t.4l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSlyy - a ,; INTENDEDUSE�'- '—TYPE-OF,WELL ='PROBLEM AREA" CONSTRUCTfO SPECIFICATIONS 24ndt stria) LS Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing x ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ; 1-1 Public ❑ Other C] Delta Depth of Grout Seal Type of Grout t` I I Irrigation Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ .Type of Pump H.P. State Work Done Well Destruction ❑. Well Diameter Sealing Material (top 501 Depth Filler Material l8elow 50') t^ TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION ! 1 DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) 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 Distance to nearest: Well Foundation Property Line LEACHING LINE"" 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 6— rules"and-regulations-of-the-San�:doaquin Local-Health Di'strict'. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject toy 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 California." The applicant must l for all re u d inspections. Complete drawing on reverse side. Si d X Title: Date: R DEPAR ENT USE ONLY Application Accepted by ;71Date Area Pit or Grout Inspection by Date Final Inspection by Date / L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Nfanteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all conies to:_Envirnnm_entAt Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -7413`42 - /.cell 457t7FEE G/, INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE p�PERMIT IVO. . EH 13-24(REV.I/Kb) '� S0,00 lei b1 1-7-0-91 U-rte �lV I� EH 14-M n