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p ES APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL l ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROWDATE ISSUED kZ aA. r {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 Ipump and the Rules and Regulations of the San Joaquin Local Health District. ,_,, a, f 9�^ ie W Jf* city ��`+v Lot SizeXxs PM Job Address � ' r,N�� /f�}jU/ + iYJCLS�Mddress � C- f�GL� Phone �— Owner's Name �_ — Contractor ` Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION 11SYSTEM REPAIR ❑ _ OTHER ❑ 'DISTANCE TO~NEAREST:SEPTIC TANK � SEWER EWES � DISPOSAL FED. '.PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca ._Dia of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ED Other C3 Delta Depth of Grout Seal Type of Grout ❑ Irrigation L—Approx`Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. —State Work Done Seating Material {to 50'}f Well Destruction ❑ Well Diameter 9 p Depth Filler Material .Melow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence —t Commercial— Other Number of living units: Number of bedrooms Character of soil to-a¢depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg %4^,4G Capacity No. Compartments PKG. TREATMENT.PLT. ElI Method of.Disposal. Distance to nearest: Well Foundation Property Li e.%_dV" r} LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance lto nearest: Well Foundation Property Line SEEPAGE PITS B"'Depth - Size Number SUMPS. Cl.. Distance.to nearest:. Well Foundation- Property Line— DISPOSAL ineDISPOSAL PONDS ❑ .-'! -- 1 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.�s %. Home owner or licensed agent's signature certifies the following:"I certify that in the,perfor ance, of the work for which this permit is issued, I shall not employ any-person in such manner as to become conipensatidn 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 applicant must call f - II required inspect; Complete drawing on reverse side. Signed Title: Date: I FOR DEPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout inspection by Date Final Inspection dbyaDate3- 24 Additional Comments: / ❑ Stk 466-6781 ❑ Lodi 389-36'21 ❑ Manteca 823-7104 ❑ Tracy 83 5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i' C t FEE AMOUNT DUE AMOUNT REMITTEE} RECEIVED BY 5DDATE PERMIT'NO. f INFO + EH 13.24 IREv.i/a 51 �S^ �Sr a o r� EH 1426