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# APPLICATION FOR PERMIT 2W?/ SAN JOAQUIN LOCAL HEALTH DISTRICT U b • `F1601 E. HAZELTON AVE., STOCKTON, CA Telephorie (209) 466-6781 cow)p� ;4� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED( /�! 0—i 1�1- (Complete in Triplicate) i f y LAplicatidn is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This/appflcarlq de 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 Joa al Health District. Address `7 / �, L� T City r �ot Size Q PM ner's Name %G.e%VIAI DL Address /� Q �UX ��traGtor)(I - Phone Address E OF WELL/PUMP: License No. Phone �— NEW WELL ❑ � WELL REPLACEMI=NT CJ DESTRUCTIOtV ❑ PUMP INSTALLATION SYSTEM REPAIR D ISTANCE TO NEAREST: SEPTIC TANKOTHER ❑ --� SEWER LINES DISPOSAL FLD, PROP. LINE _ FOUNDATION AGRICULTURE WELL _ - OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -/ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /Q Domestic/Private L7 Grave! Pack ❑ Tracy T Dia. of Well using I Public: Type of Casing Specifications (� Other f-1 Delta Depth of Grout Seal ID(Irrigation �/f/� Type of Grout 1` 4 Q"_ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump [( Well Destruction ❑ �� .P. State Work Done Well Diameter Sealing Material (top 50'1 _ Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEIN INST LATION 17 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic q m permitted if public sewer is Installation will serve: Residence, mms Other avaifab ithin 200 feet.) m Number of living units: Number of Broorooms Character of soil to a depth of 3 feet: `SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ apacity No. Compartments Distance to nearest: W Method of Disposal Foundation Property Line LEACHING LINE ❑ No- & Length of Ii FILTER BED ❑ Distance to rest: Well Foundation length/size l Foundation_ Property Line SEEPAGE PITS I I D th SUMPS 51ze Number Distance to nearest: Well 015POSA1 PONDS undation. �...�-_ .,, ;Property Line 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 of licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt 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 t 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." TheC Ltmust call for all required inspections. Complete drawing on reverse side. w Sign Title: Date: ; � FOR pEPARTMENT USE ONLY Application Accepted by J Pit or Grout Inspection by Date Arep_ Date Final Inspection by Additional Comments: ❑ Stk 466-6781 C1Lodi 369-3621 ❑ Manteca 823-7104 r�- ❑ Tracy 835-6385 �• Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAO 't2 FEE AMOUNT DUE INFO \ AMOUNT REMITTED RECEIVED BY CASH DATE EH 13-244n EV.1/g5l 9 A Err 14-26 S .C7 �7CJ U� 32-5 f Vvhm ..