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T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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. , J Z L.G[ City 1 Lot Size aC PM Job Address /- 37Pe g 3 Q Owner's Name AddressA es* Phone /`� �� Q I,� -7Q Contractor P� Address eed ka 0 License No. 040`x.(_Phone u r 'p3 J TYPE OF WELL/PUMP: .. NEW WELL 91 WELL REPLACEMENT LlDESTRUCTION 11 PUMP INSTALLATION 0� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1001.. SEWER LINES — IC01 DISPOSAL FLD.fin{ PROP. LINE _.� t FOUNDATION , �f ' AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL € PROBLEM AREX—CON STRUCTION-SP-ECIFICAT.IONS. �D y i ❑ Industrial ❑.Open Bottom ❑ Manteca lig Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private IJ�Gravel Pack r❑ Tracy,- Type of CasingIg e Specifications Cl Public Ll Other 'F1 Delta `Depth.of Grout Seal 0 Type of Groutco I Inigation .___.Approx. Depth .I I EasternAyrSurface Seal Installed by Repair Work Done ❑ Type of Pump ti f H.P. '' �4 °' State Work Done1. Well Destruction ❑ Well Diameter I v�,i,Sealing Material (top 50'1 Depth Filler Material �elaw 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION I I' REPAIR/ADDITION 1.1 DESTRUCTION l I (No septic system permitted it public sewer is available within 200 teat.) r 'r' Installation will serve: Residence— Commercial= Other t s Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` } Water table depth SEPTIC TANK ❑ Type/Mfg t1CjI Capacity No. Compartments Method of Disposal. PKG. TREATMENT PLT. Fl � f 1 � � - k Distance to nearest:- Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line r SEEPAGE PITS I i Depth { Size Number [ SUMPS Ll Distance to nearest: Well ,Foundation Property Line f "DISPOSAL PONDS ❑ ` r 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 fallowing: "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 applica st call for all required i sspejctions. Co plat rawing on reverse side. /"f i Title: 2 f e Date: y^q, - Signed X s ` r OR DEPARTMENT USE ONLY ( Application Accepted by I Date Area is Pit or Grout Inspection by Dates is �3 Final Inspection by, $_� � � Dalo.` Additional Comments: ❑ Stk 466-6781 O Lodi 369-362 LI Manteca 823-1104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P`.0. Box 2009, Stk., CA 95201 f KF � AMOUNT DUE AMOUNT REMIl7ED CASHRECEIVED BY DATE PERM17NO. +.EHi324IREV.I/R5110 —0 Y174 !� �� 13 O� 7 I 3 `6 �-r9 61 EH 142l