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" APPLICATION FOR PERMIT x SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA �� N Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 Address �Q� City Q� Lot Size PM Owner's Name Address f/4-1'71 "41 14141-1,J127. Phone Contractor Address�—'2/2:t� No.146f ZY.2 Phone TYPE OF WELL/PUMP: NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1®` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ,, 'f c= �Type.of Casing } I/`l_ �Specfications�! ❑ Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout REX1 (�� ❑ Irrigation 62Approx. Depth ❑ Eastern Surf. eASeat Installed by G @ V Repair Work Done ❑ Type of Pump � r H.P. t State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 50') ' Depth I i Filler Materia! (Below 501 ! TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is available within 200 feet:) ! CA n Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms sA # Character of soil to a depth of 3 feet: Water.table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of C]isposal 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 ❑ � I hereby certify that I have prepared this application and that the work will be done in accordance with:San Joaquih county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ,] j 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.''Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shalliemploy persons subject to workman's compensa- tion laws of California." 1 y JS The applicant s l' o alt req'. in pections. Complete drawing ongr ,6"eice. Signed Title: * Date: � 1 S` FOR DEPARTMENT USE ONLY Application Accepts y ` Date / Pit out spec y Date_.,�_' t-f� Final Inspection by - Date Additional Comments: ( I � 5 lu I 1 l^" � h ��c 's ��69 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M n eco 823-7104 Ii 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 GASH RECEIVED BY l?AT--T PERMIT''NO. INFO +EH 13-24 iREV.1/6 51 EH 1426 ...•.------- .'i ; �-- ._3 1_ T\P= C7 i