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. i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.:HAZE; TON AVE., STOCKTON, CA Telephone {209) 466-6781.. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete.in Triplicate) : n 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 compiiance 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 V0 v(fw' u City L Lot Size g PM d Owner's Name Address 11T V `I IV 1 J� `�.J_ Phone - Contractor's Name ��. U ��I License No. e3f 3 71�6' Phone u cr TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. f PROP. LINE FOUNDATION. t AGRICULTURE WELL OTHER WELL4 PITS/SUMPS INTENDED USE t TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. e I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i, Dia. of Well Casing. ?"omestic-7rivatP e��❑ Gravel Pack a ❑ Tracy Type of Casing f Specificationsr' ❑ Public ❑ Other ❑ Delta Depth of Grbut eaI Type o rout r ❑ irrigation ---Approx. Dep ❑ Eastern Surface Seal Installed by 71L)S L� t Repair Work Done El Type of:Pump H.P. A- • ' ' State Work Done Well Destruction ❑ Well Diameter Sealing,Material /tap 50')4- ;r _ d •_ _ { —Depth= - —Filler Material (Below-501- TYPE OFiSEPT WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.)3 f Installation will serve:' Residence Commercial_ Other Number of living units: 1t,..Number of bedrooms y ; 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 i Qistance`to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size— FILTER ength/size FILTER BED ❑ Distance-to nearest: Well Foundation Property Line '' 3 J :;1 fres . SEEPAGE,PITS) ❑- 'Deptfif, Size Number SUMPS ❑ '6istance 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 pe n in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or'sub-contracting signature certifies the fol ing:"I card that in the orma a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C I ornia." - I i i; The:applicant call for a r wired in tions. omplete drawing on averse side. t Signed X Title: ,.......,,-. Date: 4FOR DEPAR ENT USE ONLY Application Accepted by - Y 47 Qata� { `'� �� Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: UI ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r..,,...._....,._....... Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. a y FEE } INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'-NO.' +EH 13-24(REV.10183) q!57,00 ND Tr3 EH 1426