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APPLICATION) FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AhVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I i (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a peI.rmit to construct and/or install the work herein described. This application is made in compliance with San Jda'quip County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City r� �`' Lot Size PM Owner'g Name Address.�I Phone �F9. -'�-.�-�.�.-r-.- .�+.4-.w.w4j�=.�.+w:4-+�'^..r��r».a.s+r�.+-r.-!+rt.o�...-.��..rw".-..+. -� --..» . ......r - ...... .,.b•• 7 W g Cpr1l�'a`tar _ -Address License No Phone TYP hDF WELL/PUMP: �� NEW WELL ❑, r WELL REPLACEMENT D DESTRUCTION CI `.} t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ jDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �M DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I n Industrial ❑ Open Bottom ❑ Manteca Dia.'ot Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications A (-1 Public n tither F1 Delta Dep h of Grout Seal Type of Grout I Irrigation 4-Approx. Depth I I Eastern Surface Seal Installed by i Repair Work Done L7 Type of Pump H.P. �M State Work done_ r. Well Destruction 11 Well Diameter Sealing Material (top 60') 4 Depth Filler Material Il Below 501 t TYPE OF SEPTIC WORK: , NEW INSTALLATION [ REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is I o: available within 200 feet-1 _ Installation will serve: Aesidlence�` Commercial_ Other • Number of living units: _I Number of bedrooms '.h R �-,�� .. = V% Character of soil to a depth'of 3 feet:_ n Y '� Water table depth t SEPTIC TANK EI - Capacity No. Compartments- PKG. TREATMENT PLT. ❑ I� �T Method of Disposal 4 Distance to nearest: Well eLu�p Foundation �00 --.Property Line l LEACHING LINE �No. & Length of lines '�" f1 I� Total length/size d ' z FILTER BED ❑ Distance to nearest: Well�Q Foundation _ .._-- Property Line 1 �� SEEPAGE PITS .I NDepthS�`ize Ir Number SUMPS Cl Distance to-nearest: Well Foundation Property Line x DISPOSAL PONDS ❑ I hereby certify that I have prepared thistrbpplication and that the work will be done in#accordance with San Joaquin county ordinances, state laws, and rules'and-7egulations of the San Joaquin Local Health Di1trict. 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." I ' The applicant must call for li�requi inspections. Complete drawing on reverse side. r Signed X TitlIe: Q Date: Jr is I!I ZF DEPART ENT USE ONLY ( Application Accepted by Date ¢ rea s nni Pit or Grout Inspection by 'll Date I Final Inspection by Date FAdditional Comments..,��...�..__..--....r.......,-�.�,.,...�...".._.r..-:..,..._.I��_......-_,-....•..... .........._�-» �- ...-�:.---.._---• -....-...a.�--. - .-., -,.._------ Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 �� ❑ Tracy 835 6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 s IIS i�' t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO .w CASH N +.EH 13-24 1 - .1r. / ~1,,,[� EH 14-2e / 1 `�+ 1