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it Acr Ii APPLICATION FOR PERMIT ii SAN JOAQUIN LOCAL HEALTH DISTRICT I' 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. !` k Job Address T)t � L l�� Ci3` '(� Lot Size `-+rt PM Owner's Name jl " ��1 Address O` � n W` tF _ "-__ Phone Contractor's Name License No. "� s �I — Phone�� J TYPE OF WELLIPUMP: P", ANEW WELL_❑ WELL REPLACEMENT .0, DESTRUCTION ❑ PUMP INSTALLATION ❑ ' SYSTEMREPAIR ❑ ''`mss OTHER ❑- w DISTANCE TO NEAREST: SEPTIC TANK --SEWER LINES 'DISPOSAL FLO, PROP. LINE FOUNDATION !�.ZAGRICULTU'RE-WELL OTHER WEL :PITS/SUMPS INTENDED USE TYPE OF WELLS PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom/ ❑ Manteca T Dia. of Well-Excavation - - _-Dia. of Well Casing ❑ Domestic/!Private El Gravel Pack ❑ Tracy- Type ofXasing - i Specifci ations ❑ Public ' ❑ Other ❑ Delta 1 Depth-of"Grout Seal -- Type of Grout ❑ Irrigation�- Approx. Depth ❑ Eastern Surface Seal Installed"by - _ 0 Repair Work••Done El Type of Pump H.P. State Work D -- Y 10. Well Destruction ❑ Well Diameter Sealing Material (top 50'1 l7J I k I Depths Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (II N available within 200 feet.) 1 Installation,will serve: Residence'` -Commercial_ Other *Number of"living units: it Number of bedrooms --ti_.$_Character of soil to a depth ofl3 feet: mr ^� - _ Water table depth -- - ! R A _.JV ti�r 1 N . SEPTIC TANK ❑ Type/Mfg 'Capacity` No.-Compartments PKG. TREATMENT PLT. ❑ �� r __ - Method of-Disposal - Distance to nearest: Well Foundation - Property Line LEACHING LINE ❑ No&Length of lines �r X, Total length/size FILTER BED ❑ Distance to;nearest: Wel! ,,Foundation Property Line SEEPAGE PITS ,O Deptht A X -SizeF � Number v 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 1h accordance with San Joaquin county ordinances, state laws, and .x rules and regulations of the San Joaquin-Local Health District. ", a Home ovver 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 certifiesLfollowingr- ,' certify t a in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensa- tion lawias.The appII fo ail r uir d inspections. Complete drawing"ori reverse ide. .Signed it ' ' Title: � 4 Date: E 11 //0 DEPARTMENT USE ONLY a i # Application Accepted by. Date Area Pit or Grout Inspection by I '' Date Final Inspection by Date Additional Comments:. ❑ Stk 466-6781 ❑ Lodi 11369-3621 { ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:',Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITT 'i RECEIVED-BY- DATE PERMIT`N0. INFO sy C S 7�y +EH 13-24{REV.10183)1, 0/B3! / �a/ �tr� / EH 14-26