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O 7 1� Si R APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ��, . { 1601 E. HAZEL TON AVE., STOCKTON, CA F 4 $V F_ID Telephone (209) 466-6781 i PERMIT EXPIRES 7 YEAR FROM DATE ISSUED } ; 1� (Complete in Triplicate) EAk is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herpi{t�$�>��1, r�pa'�tid'a n is made in compliance with San Joaquin County.Ordinance-No 549 for sewage or No. 1862 for well/pump and the Rules and ego Hxlsot`fli �a'ni �uin Local Health District. . , Job Address _,(![ �" / ILIJC/Q 1�� Y r `,` „ City r Lot Size ' PM I Owner's Name Address A/7 9�� T7[!�L fl.Gf__4./�-LL` A�� Phone ii "y-J_ Contractor Address .Z License No. 67,9069/3 Phone .TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'El SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:�SEP71C TANK- 509- -_SEWER.LINES;, _DISPOSAL FLD. SO, PROP.,LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private X Gravel Pack ❑ Tracy Type of Casing P.V�� Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Q,\,.—_Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done- ❑ Type of Pump H.P. State Work Done ❑ Well Diameter Sealing Material (top 501 I Mr tt t–t t$ Depth, Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if 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. ❑ 11 Method of Disposal _ Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: WellFoundationProperty-Line _ - a DISPOSAL PONDS ❑ a 1 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 ` 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 permit is issued, I 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 tliat 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 ust call for ail req"' d inspections. Complete drawing on reverse side. Signed X 2 64k Title: Date: (j g7–� –F O FOR DEPARTMENT USE ONLY ��p� t Application Accepted by QQ Date , Area Pit or Grout Inspection by ` Dat 06 Final Inspection by Date Additional Comments: B y�� ❑ Stk 466-6781 ❑ Lodi 369-3621 I ❑ Man ca -7104 1 ❑ cy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE a � INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. J ((* EH pJ _,_ � �_3EH 14-2e PQ