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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT o 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781JUN 3 19$g PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) ENAROMENYAL HEA1-TH ��TgSERVICES Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the w r n escribed. 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 City Lot Size PM Owner's Name Address 4Z Phone __49V fK dw Corntractar fiftdT .11X [' ' Address��77�-5/5 -.mss, u44z & License No. SS ® Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑' SYSTEM REPAIR ❑ OTHER A4e CI�� DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINELN FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca t 4 Dia. of Well Excavation Dia. of Well Casing V_Domestic/Private ❑ Gravel Pack LlTracy ,. Type of Casing Specifications M Public Ll Other p ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation --Approx. Depth I I Easternt r Surface Seal Installed by _ Repair Work Done Type of Pump. H.P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 ��A AWfi +�- Depth Filler Material IBelow 501) - TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I 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 z $ r Character of soil to a depth of 3 feet: F .' ' Water table depth .SEPTIC TANK ❑ Type/Mfg Capacity-- -�No. Compartments PKG. TREATMENT PLT. ❑ a = Method of•Disposal Distance to nearest: Well, Foundation Property.Line LEACHING LINE ❑ No. & Length of lines I Totallength/;ize FILTER BED ❑ Distance to nearest: Weli�--' Foundation Property line SEEPAGE PITS l I Depth F Size Number bf r SUMPS Cl Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ # 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 shalt 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 applicant rpust call r all required inspections. Complete drawing on r erre rde. t Signed X c c Title: c� Date: F. WDEPARTMENT USE ONLY } Application Accepted by Date Area ' Pit or Grout Inspection by F� Date Final Inspection by Date S Additional Comments: ❑ Stk 466-6781 If Lodi -3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envoi-rronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT.REMITTED CASH RECEIVED BY DATE PERMIT'NO. i +.EH 13.2 R in51 J ^� i EH 14.29