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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 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 Address0#45,CGF1fi1/Tf N0011 (F MW GflVFF AKWZY af 971C� 'SSZIC� � Lot Size PM Owner's Name Address WMPhone Contractor 64L&A7Wcess U -cense No. -Phone667- TYPE OF WELL/PUMP: NEW WELL'-- WELL REP ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 0- DISPOSAL FLD. = PROP. LINE .. r FOUNDATION AGRICULTURE WELLO�. OTHER WELL&2� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS „ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1.3/A(W- Dia. of Well Casing ❑ Domestic/Private $-Gravel Pack ❑ Tracy Type of Casing P(/c 11CAf-- /11/10 Specifications '(,�'Rublic ❑ Other tj�r-Delta Depth of Grout Seal Type of Grouth 1 _ I I Irrigation F&,Approx. Depth ( I Eastern Surface Seal installed by Repair Work Done' ❑ Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1:) REPAIR/ADDITION I 1 DESTRUCTION I I (No 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 71 , LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 'I ! SEEPAGE PITS l I Depth Size Number SUMPS Cl 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. 1 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 appli ust all r all re Iced inonspections. Complete drawing ra e e side. Signed X Title: Date. OR DEPARTMENT USE ONLY � Applic Accepted by Date Area Pit or Grout),spection b t' j ate Fin I Ins a on by Additional Comments: / f ' ❑ Stk 466-6781 ❑ Lodi-369-362.1 _"_:_E'Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environ ental Health Permit/Se Ices 1601 E.liazalton Ave., P.D. Box 2009, Stk., CA 95201 'G f es- tr� INFO CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. •.EH73-24(REV.1/951 '143,,/q0JCFo_joo� EH tt-2a 0