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�p APPLICATION FOR PERMIT II SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 4A,&4AH— I+ PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �I (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 - rl t n City Lot Size PM Ip i ! I'a,�� - Phone Owner's Name � ��.Address• i ContractorNLA.tiIt WSLL161_Address C C�� ^ r License No,'� Phone TYPE OF WELL/PUMP: NEW WELL P5, WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTALLATION L SYSTEM REPAIR ❑ OTHER ❑ A� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.gj=-_ PROP. LINE ! + FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS O 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 Ll Tracy Type of Casing Specifications 1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grou i Ij' 1�Irrigation -A. Depth., l I Eastern Surface Seal Installed by - �' P. State Work Done _ .Repair Work Dane ❑ Type of Pump Well Destruction D Well Diameter Sealing-Material (top 501 Depth Filler Material (Below 501 � TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1.1 DESTRUCTION I I INo septic system permitted if public sewer is x available within 200 feet.) Installati- or will serve:_ flesidence _. Commercial - Number of living units=Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK. : 0 Type/Mfg _ Capacity y �No. Compartments PKG. TREATMENT PLT ❑ I Method of Disposal Oistarice to nearest:" 'Well'— — -"'FoOridatibn """'"`Property Line � t LEACHING LWE ❑ .No. &.Length of lines. - Total length/size t, I FILTER 9ED { ElDistance to nearest: Well, Foundations Property Line SEEPAGE PITS•K I I, Papth Size Number SUMPS ❑ ;Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ 4444 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. y 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, k shall not r employ any person in such manner as to become subject to workman's compensation laws 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,rI.shali employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing-on reverse side:" A ' .� r7 h e•— r~� y Signed X Y Title: K&�` C-I Date: (J + y FOR DEPARTMENT LISE.ONL•Y 4 rf Application Accepted by r Date Z.a Area t Pito Grout nspectio b Date incl Inspection by Datel6,7 Additional Comments: II E) Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El 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 DUET AMOUNT REMITTED ' RECEIVED BY DATE PERMIT-NO. - . INFO +.EH 13-24(REV.1/85) .� .1 4 13 � 94L, EH 14-26. 1