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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Y p I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. /�, —SO Ld 15Ae PM Jab Address � �J �� J �. a City Lot Size_- o R Owner's Name + o M051111h e s Address Phone 3Q�S Contractor e Address .._;51 hP, _ License No. Phone TYPE OF WELL/PUMP: j FNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El ' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ! FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS JINTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Q Gravel Pack. ❑ Tracy Type of Casing Specifications M Public Cl Other Cl Delta Depth of Grout Seal Type of Grout • I l Irrigation —_Approx. Depth I I Eastern Surface Seal Installed by t� Repair Work Done ❑ Type of Pump H.P. State Work Done_ Weil Destruction ❑ Well Diameter Sealing Material (top 50'1 , Depth f_ - Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is X 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: r/ Water table depth kA SEPTIC TANK ). Type/Mfg, ct- Capacity—L6-0-0— No. Compartments PKG. TREATMENT PLT. ❑ 1! 1 Method of Disposal L- L �,,� Distance to nearest: Well �a{6 Foundation,.�v ._ Property.Line I LEACHING LINE 17( No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well--_j-, Foundation Property Line C - ` SEEPAGE PITS I I Depth + Size _ Number S SUMPS Cl' Distance'to neatest: Well' Foundation Property Line ' DISPOSAL PONDS ❑ l 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. 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 notes 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 applican st call for all required ins ctions. Complete drawing on reverse side. Signed X- Title: �r� Date: FOR DEPARTMENT USE ONLY Application Accepted by ' Date Pit or Grout Inspection by Date Final Inspection by Dater ✓ u Additional Comments: ❑ Stk 46&6781 ❑ Lodi 369-3621 Cl 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 CK Ot RECEIVED BY DATE PERMIT NO. INFO !f ,.+j �y(� CASH +.EH 13-24 f REv.t/H 57 l b'A� -/�-�""' EH:4.29 r_ ! 6S"