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rt APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTA 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED .l "(Complete in Triplicate) i 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 No. 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. �„ o ZAZI /! / , j City Job Address f t �T� Lot Size r�Vf f�Or PM Phoned 253 Owner's Name _ Address ��77 ' �a,� (� �1L /So tiJ�1 ti a A► V License No. 3J 4 Phone g43cstV Contractor +M `A� -� Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD:- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL- INTENDED r INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � k ❑ Industrial ElOpen Bottom ❑,Manteca Dia. of Well Excavation Dia. of Well Casing 13 Domestic/Private ❑ Gravel Pack ❑Tracy Type of.-Casing Specifications I'1 Public f-1 Other Fl•Delta Depth of Grout-Seal Type ofGrout I 11 Irrigation --.-Approx. Depth 11'Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 1 f--H-P_-� State Work Done r .-.-` l-[top 5�b'�""�'""""` t Well Destruction ❑ Well Diameter { c Sea ling'Materra = - a ! Iw Depth Filler Material IBelow 50'I' TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION DESTRUCTION I 1 (No septic'system permitted if public'sewer is available withir'200 feet.). ii Installation will serve: Residence✓Commerc l Othet Number of living units: J— Number of bedrooms ,_: i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg } Capacity^ No. Compartments ;Method of,Disposal f PKG. TREATMENT PLT. d , Distance to nearest: { Wel! foundation Property Line 1 t ��A --------------- LEACHING LINE L� No. & Length of lines Total length/,size FILTER BED ❑ Distance to nearest: Well Foundation Property Line- SEEPAGE ineSEEPAGE PITS 11 Depth Size Number SUMPS Ll Distancefto,,nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ I 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 wcirkJoi which this permit is issued, I shall not mploy any person in such manner as7 to become subject to workman's compensation laws of California.`;Contractor's hiring or sub-contracting signature •certifies the following: "I certify that 1- spections. rformance of the work for which this permit is-issued,_k sh_a_II_ePnploy_petsons subject to workman's compensa- tion laws of California." .The applicant II for a requiComplete drawing on reverse side. Signed X f' Title: �ns�� r Date:' � I - o- S7 t �4FOR-DEPARTMENT USE ONLY y r /-A 'FDate I' + / Area Application Accepted by _� k y Pit or Grout Inspection by t Date Final Inspection by Dat Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2409, Sik., CA 95201 FEE AMOUNT DUE n AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO ] ` r r EH 13-241HEV.-t!'n51 sr lfz�O. y EH 14.29