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'�•�` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZEL T ON AVE., STOCKTON, CA t Telephone (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 worts 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. � .fd,/' t� a Jr/ r � `--' Job Address 71 City Lot Size 2�PM J �il� Address " G Phone zz Owner's Name �1!� Contractor Address 6 off/ W7,-4 License No cA l__Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _..._ Specifications XI Public,_ _r_.,r _. ..�l�.O.ther._._.__._r..•.._.l7.Delta.. ._- _ ,.Depth.of Grout SealType.of_Grout - 'I 1 Irrroation —Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done- 'l Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 - Depth Filler Material (Below 501 TYCEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I] DESTRUCTION I 1 (No septic system permitted if public sewer is. PE OF S available within 200 feet�1p- - r� Installation willserve: Rest rice Commercial Number of living units~ .NumBer'of bedrooms Character of soil to a depth of 3 feet: ADOBE Water table depth SEPTIC TANK ❑ .Type/Mfg IN-` C a p a c i No. Compartments PKG.TREATMENT PLT.❑ g4 - Method of Disposal Distance to nearest: . Well �/ _ Foundation �� Property Line 1. LEACMNG LINE ❑ No.& Length of fines c� AZ �To- --Ie g h/size FILTER BED Distance to nearest: Well ZAQ _ Foundation :— Property Line r SEEPAGE PITS i'• I I Depth Size r r Number SUMPS Ll Distance to nearest: Well Foundation / Property Line ; Y F DISPOSAL PONDS ❑ � I hereby certify that 1 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_Yperformance 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 sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issded,I shall employ persons subject to work'man's.compensa- tion laws of California." The applicant must I for required inspections. Complete drawing on reverse side. i Signed X 1a�/ Title: Date: C FOR DEPARTMENT USE ONLY- m� } :�� .� '� Area �l�" ''t �• + r Application Accepted by Date Pit or Grout Inspection by Date Final Inspection b Date Additioilal_Comments: f C Stk 466-6781 . 11 Lodi 369-3621 ❑ Manteca 823-7104 ip Tracy 835-6385 Applicant. Ret l :nall copies to: Envirdi me6tal Health Perms it/Services•191!E. Hazelton Ave., P.O. Box 2 , Stk., CA 95201 ' L`CK FEE AMOUNT DUE AMOUNT REMITTED, RECEIVED BY ATE, PERMIT'NO. -INFO. CASH- - --p-- . _ '•� ��I ...EH 134tt IRE~, sl i EH N•2a C