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i 3 , j. APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i 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. n� J City Lo�$ize PM Job Address � 4� U o f LKJ_ Owner's Name ll� Address f Phone /J Coniractor ddress / Q License No.�_= Pho'"ne'�_. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ -DESTRUCTION LJ PUMP INSTALLATION ❑ STEM-REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SE R LI S DISPOSAL FLD. PROP. LINE E FOUNDATION AGRI U URE WELL "'OTHER WELL— PROBLEM INTENDED USE TYPE OF WELL PROSLFM ARA CONSTRUCTION SPECIFICATIONS r F L1 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing T 6 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications } s-....�...�...�m§t S FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r _ j " { A roic. Depth { I Eas rn R Surface Speak Installed by ` } I'1 Irrigation -- pp r. - Repair Work Done ❑ Type of Pump H.P. ' 4~ _ State Work Done Well Dest ction _ ❑ Well Diameter _ � Sealing Material ffbp 507 -- {�k,, 1Y Depth Filler Material-{Below 501 TYPE OF SEPTIC WORK: tNEW INSTALLATION l REPAIR/ADDITION i I DESTRUCTION l 1 Wo septic system permitted if public sewer is available within"200 feet.) M Installation-will'seNe: 'Residence' Commercial ther >� Number of living units: Number of bedrooms Characterof soil to a depth of 3 feet: If Water table depth I - V o SEPTIC.TANK L) Type/Mfg Capacity No. Compartments a PKG.'iREATMENT PLT. D - Method of Disposal Distance to nearest: Well& oundation 's Property Line 116o !. LEACHING LINE ❑ No. & Length of lines Total length/size L 111 FILTER BED ❑ Distance to nearest: Well/0L ,—` oundation Z bC)._-_.-- Property Line f SEEPAGE PITS l I Depth Size Number 2 _ SUMPS Ll Distance to nearest: Well ._ Foundation M o Property Line F DISPOSAL PONDS O ` i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin courtly ordinances, state laws, an rules and regulations of the San Joaquin Local Health Di"strict.--, t O 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 I 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 fonwhich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r:7 The applica ust callrequire inspections. Complete drawing on reverse side. I Signed X Title: Date: 2 —2J fo SPAR MENT USE ONLY [ F Application Accepted by Data Area I Pit or Grout Inspection by Date Final Inspection by Date 11 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦,Ell 13-244REV.1/x51 YEN 1 y„ . W O`- .0.J� •(�' ��3 ' T H 1428