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n " APPLICATION FOR PERMIT Od SAN JOAQUIN LOCAL HEALTH DISTRICTI C /} tvl 1601 E. HAZELTON AVE., STOCKTON, CA I/fi f�C L pvt, 1 iTelephone (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 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. �j/y /� Job Address 5�!11 / f 1�—��G/ - City ,L Lot Size PM Owner's Name Address /01a $ 51V Phone AA' Contractor ddress Gpjd License No. '7o Phone TYPE OF WELL/PUMP: 1 NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION j SYSTEM REPAIR ❑ OT EI� 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD. PROP. LINE 32 FOUNDATION AGRICULTURE WELL r OTHER WELL--=nPITSlSUMPS—::= v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION } �Y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation , Dia. of Well Casing L )0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing joyC Specifications F1Public 1-1Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation �_Approx. Depth t I Eastern rr ace 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 (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION I i 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ 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 rules and regulations of the San Joaquin Local Health District. s 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." The applicant t fo all r pections. Comprawing an re se— de. Signed lete dTitle: �6 �' i Date: FOR DEPARTMENT USE ONLY �r Application Accepted by __ Date f g 4-4 Area 0r' Pit or Grout Inspection by Date��Final Inspection by Date/G 1322 if 7e Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Cx RECEIVED BY DATE PERMIT'NO. INFO CASH +.EN 13-24 IREV.i i 4 sl 9 EK 14.26 4