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APPLION FOR PERMT SANJOAQI,..` �., .AL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA C►.�'"�p Telephone (209) 466-67$1 1 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 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. Job Addressl/./�Z1rU city��C Lot Size PM Owner's Name t' rtv Ac W a V. Address _____�[�.wn �_ �� , Phone Contractor's Name t'" t�i r• L� �kicense No. �J DS/U _ Phone _[ TYPE OF WELL/PUMP: NEW WELL.El WELL REPLACEMEN DESTRUCTION ❑� PUMP INSTALLATION ❑ SYSTEM REPOTHER ❑ tAu'11SPOSAL DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FLD:"r,.--"I PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL'`.- /�� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA- CONSTRUCTION SPECIFICATIONS * k ❑ Industrial ❑ Open Bottom ❑ Manteca +,� ' Dia. of Well Excavation Dia. of Well Casing ;,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing n �^ i Specifications ❑ Public ❑ Other ❑ Delta_ Depth of Grout Seal : Type of Grout ❑ Irrigation --Approx. Depth 1P Eastern Surface Seal installed by Repair Work Done Type of Pump H.P. Sy State Work'Done Y✓� Well Destruction ❑ Well Diameter r Sealing Material [top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-1'9 ❑ (No 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 -f PKG. TREATMENT PLT. ❑ Method of Disposal #. Distance to nearest:. Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: ��Well Foundation Property Line DISPOSAL PONDS ❑ 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. i 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."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." J The appli us all,for all req d ins tions, mplete drawing o verse side. Signed ri Title: 7l S Date: E OR DEPARTMENT USE ONLY Application Accepted by "01�, _10- yry� Date *OA1` 77 Area Pit or Grout Inspection by Date Final Inspection by Date 1 Additional Comments: ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑.Tracy 835.6385 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE INFO MOUNT DUE AMOUNT REMITTED CASK C) r CK RECEIVED BY DATE PERMIT"NO. +EH 26 W EH 1426 Ey.10183) 01�1y •.J GGG ?� _