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s r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RECEIVNr (Complete in Triplicate) off J1rP Grp Application is hereby made tolthe San Joaquin Local Health District for a permit to construct and/or install the W4hreinlscnbed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump,atli!the Rules and Regulations of the San Joaquin Local Health District. 1 NAAEN7 � rC3l.i+� (�W rl L..; ori Job Address City Lot Size �a PM lV , � �a��/r q Phone Owner's Na�meT(, ddress Contractor Address gw3 maA License N1;2_ Phone TYPE OF-WELL/PUMP: _NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION�!rl SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE -; .••-�-•""""'-"""""""`"""'c""'^"FOGNDATION`�`"-"""""`""'"'AGRICULTURE WE-- LL.,'..e._OTHER-WELL ---�.,� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing XDomestic I Private E1!Gravel Pack ❑ Tracy Type of Casing Specifications t' # ❑ Public [7.Other ❑ Delta Depth of Grout Seal ' J Type of Grout ; _- 1I irrigation 7 'Approx. Depth I I Eastern Surfac S I Installed by Repair Work Done � Type of Pump � H.P. ��.1 — State-Work. p�r Well Destruction ❑ Well Diameter Sealing Material Stop 50'i _ / L;�w �lUr(~".� Depth Filler Material (Below 501:. } t TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION l 1' DESTRUCTION l 1 INo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Corrimercial_ Other Number of living units: ! Number of bedrooms Character of soil to a depth"of 3 feet: Water table depth SEPTIC TANK 1-10Type/Mfg Capacity No.'Compartments PKG. TREATMENT PLT. ❑ i Y' � a Method of Disposal Distance to nearest: Well Foundation Property Line I � i LEACHING LINE ❑ I.No: & Length of lines ( Total length/size kFILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS t 1 i Depth SSize t Number t SUMPS ,, �, 1 Distance to nearest: Well Foundation �' Property Line ' DISPOSAL PONDS ❑ , .: _. I hereby certify that 1 have p�ppared this application and that the work will be done in accordance with San Joaquin county ordinances, state Maws, and rules and regulations of the San Joaquin Local Health District. I y 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 taws of California:"Contractor's hiring or subcontracting signature certifies the following: "I certify tKat 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." il� ? The applican ust call for ail requir d " spec ' Complete drawing on rev sa side. t x �. ! Signed X 'I� Title: [(l�.�T. �- " Date:--� _�k DEPARTMENT USE ONLY ,L -71 Application Accepted by Date '�`/y Area Pit or Grout Inspection by ;I� Date Final Inspection b. DatQ/ 'll, Additional Comments: l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies;to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO + gC H + EH 132 (REV.i H5Y 3� �" { ��/�-�rj �� 975 EH 14-2eib