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f APPLICATION FOR PERMIT T r SAN JOAQUIN LOCAL HEALTH DISTRICT +J 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 U 114—p-.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. 1562 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. J /�A Joh Address ?/5- �QL' city �� Lot Size X PM Owner's Name �f W Address C- X1611 L1 Phone Contractor g l/ of �� . Address/"a&x 1329 License Nb.Y VI- PhoneSZ, --S'41 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION a PUMP INSTALLATION X1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK X-E-0 SEWER LINES ��`� DISPOSAL FLD.,t_r� PROP. LINE "L FOUNDATION Lam" AGRICULTURE WELL- OTHER WELL — PITS/SUMPS �- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 f ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation IJ Dia. of Well Casing] U Domestic/Private Gravel Pack C] Tracy Type of Casing Specifications r�[�S9S l t7 Public / ❑ Other 11 Delta< Depth of Grout Seal Type of Grout 2 i ❑ irrigation �t�(0 -htia±�Approx. Depth Lf7 Eastern % Surface Seal Installed by Repair Work Done ElType of Pump VP H.P.,/ -- State Work Done �1 Well Destruction "l Well.Diameter Seating Material (top 501 \ Depth atFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ava ble within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of edrooms O 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 t Distance to of We Foundation Property Line_ 1 LEACHING LINE ❑ No. & Length of s Total length/size n�n FILTER BED 11Distance to rest: Well Foundation Property Line I" SEEPAGE PITS ❑ D,Ft< 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 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 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 applican must call for all required ins tion . Complete drawing on reverse side. Signed Title: ►"'�"r Date: I�� FOR DEPARTMENT USE ONLY g J Applica ion Accepted by Date r Area rt or rout Inspection Dat e Final Inspectionl�ft�e_ _ _r Date Additional Comments: YY� Id � �� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823'1104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.r CA 95201 C! f f �-7�_0 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO ��cc11 + EH13-24(REV.1/65) EH 1429