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�_r S " v APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED sl. (Complete in Triplicate) Application is he[eby 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. r 1 ` I lL qE V40-y— V1, C Cit 7� Job Address �1/ y {/ Lot Size PM Owner's Name A(r /lT NE✓CSAddress 790 2� �MC A �W -Phonerc Contractor �r]n.t�nr Address License No. LUal Phone TYPE OF WELL/PUMP: NEW WELL WWELL REPLACEMENT ElDESTRUCTION C-1I PUMP INSTALLATION '"SYSTEM REPAIR ❑ OTHER' ❑ { DISTANCE TO NEAREST: SEPTIC TANK) SEWER LINES *14n r9 t f DISPOSAL FLD PROP. LINE . t FOUNDATION; AGRICULTURE WELL OTHER WELL 4Z.,14 PITS/SUMPS !3-&o V t INTENDED USE" TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ ldHustrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing Domestic/Private ❑ Gravel Pack ' ❑ Tracy Type of Casing Pc/ ( Specifications _- 'f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation .-Approx. Depth 'I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H,P. '* f- State Work Done I Well Destruction ❑ Well Diameter I Sealing Material )top 50'i Depth Filler Material (Below 50,') i TYPE OF SEPTIC WORK:'-NEW INSTALL ION REPAIR/ADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is -+ available within 200 feet.) Installation will serve: ' Residence t Commercial 4— Other Number of living units: ___ Number of bedroomsCCN y _ Character of soil to a depth of 3 feet: r � '�.J2�-S ateraable depth r SEPTIC TANK ❑ Type/Mfg 1 G Capacity_.e?,4�pja. No. Compartments Z { PKG. TREATMENT PLT. ❑ - .,,�Method.of Dis osal Distance to.nearest::�Wel/I -_ Foundation Property Line LEACHING LINE No. & Length of Unes x Total length/size FILTER BED ❑ Distance to nearest: Well T-per Foundation Property Line - _- i h SEEPAGE PITS 1 1 �{]epth Size -2-- Number SUMPS I�/Distance to nearest: Well._�,� Foundation Property Line—-44 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 Do%trict. * 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." The applicant must call fora required ' / ns Comp_ late drawing on reverse side. �7 Signed X /'(x�C� �r Title: Date: FOR USE O LYApplication Accepted by �:�=PARTMENT Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Commei _ - `_ - ❑ Stk 466-6781 ❑❑Lodi 369 362 '0 Manteca 923-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slk., CkS5201 FEE INFO MOUNT DUE " AMOUNT REMITTED CK 7 (/�C�A�SH RECEIVED BY DATE PERMIT NO. +. i4-28(REV.i i K sl D C �� j/ EH _. 5