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r ' APPLICQ►TION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZELTON AVE., STOCKTON, CA - Telephone (209) 466-6781 _ .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) 8 Application is hereby me8e 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., �. �9MA � Job Address City pu - .--,,_Lott Size PM f/ ' y f �!�a lz � C1F -i Phone Owner's Name i �it1_i ISM 14 F�AI Address ��.-- 7 _ - Contractor I`u� ("f �� Address d License 14o.�—Phone_ 7 TYPE OF WELL/PUMP`. NEW WELL Ik WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �Q T SEWER LINES DISPOSAL FLD. PROP. LINE '- FOUNDATION 0 AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATJPNS [r ElIndustrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing KDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_h # I I Irrigation _--Approx. Depth 1 1 Eastern Surface Seal Installed Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_.- 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 Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS r. S' 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 DiMrict. Home owner or licensed agent's signature cerlifies 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, I shall employ persons subject to workman's compensa- tion laws of California." ' The applicantest call f -all r 4 , ins ctions. Complete drawing on reverse side. Signed X n Title: �� Date: - FOR DEPARTMENT USE ONLY t; .� Application Accepted byKt'dDate/7 114 U - Area Pit or ro Inspection by r' Date 1 Final Inspection by ate Additional Comments: �1l ,� ��ZZ ��/ - ❑ Stk 466-6781 ❑ Lodi 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 DUr. AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. INFO V �l +.EH 1324 IHE-V.t/x sl O �! EH i4-26 ✓✓✓ +l/