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APPLICATION FOR PERMIT {, SAN JOAQUINLOCAL HEALTH DISTRICT k rc 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES4' YEAR FROM DATE ISSUED' ' {Complete in(Triplicate) Y 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 R4Ies and Regulations of the San Joaquin Local Health District. - AJob Address-� L t-V\` ; cityJ 1:, t;;h Lot Size PM; Owner's Name � S teZ Address - - -. .- ! - Phone [ + Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT Cl DESTRUCTION PUMP INSTALLATION ❑. . SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST:SEPTIC TANK ;' SEWER LINES `` e tiDISPOSAL FLD r,,1--� ,PROP. LINE ' .FOUNDATION' .y .AGRICULTURE WELLY OTHER,-WELL yPIT51SUMP5 �= �� y - INTENDED USE TYPE OF WELL' - PROBLEM AREA CONSTRUCTION SPECIFICATIONS EJIndustrial N y`2❑-Open Bottom ❑ Manteca a�t��.Dia. of.Well Excavation' L_�• ��k'Dia r of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy- \ *Type of Casing—v- Specifications �. 1 Ll Public L) Other ❑'Delta Depth of Grout Seal Type of Grout ° � El Irrigation �.�•',Mt' �'` pprox.;Depth,, E] Eastern , Surface-,Seal Installed by Repair Work D(ne `0.❑ Type of Pump y H.P. .\ State Work Done ` t ti Well Destruction' IC]' 'Well Diameter Sealing Material (top 50') ' x `« "` t -Depth Filler Material (Balow750'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION,❑ANo septic system permitted.if public sewer is " available within'200 feet.), , -- .Ins_ -on will serve: Residence_ _Commercial_ Other 'u - Number of i� �units Number of bedrooms Character of soil to a th of 3 feet: 'Water table depth"'„ ---� - SEPTIC TANK ❑ /Mfg Capacity No. Compartments PKG. TREATMENT PLT..)F] Method of Disposal Distance to neo Well Foundation Property Line T t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foiun Property Line SEEPAGE PITS ❑ Depth Size Number ` 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 in accordance with-Sari'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 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,1 shall employ persons subject to workman's compensa- tion laws of California." _ '' :+r'Ca��%,�..,. r� `.i 'y - ..> 3. - .yp iaY�q .__-y,r =._+. --v'4- •_ 4 �.i i;'� -r— ti _ r. +�_ -- '��:-..'-�.�.-_: The applicant must call for II r wired inspections. Compiete drawing on reverse side. l � v gned Title:1�h�Ll�. Date: 4L i F EPARTMENT--USE.ONLY . Application Accepted by _'Dated Area { Pit or Grout Inspection by Date �Flnspe/ction by Date Additional Comments: C Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ' ❑ Tracy. 835-6385 w Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltpn i e., P O. Box 0 Stk., CA 95201 V FEE AMOUNT DUE. AMOUNT REMITTED CASH -� RECEIVED BY DATE PERMIT'N0. , INFO +-EEH 13 H 14-24 28 iREV.7/657} '�\ t " �/ x J f r t .�{, .•..mac _. L..`._ s.« _ .,..w..� .. ..� .Y,r .