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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i l:1 (,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 welUpump and the Rules and Regulations of.the San Joaquin Local Health Distfict. i Job Address y ]� o trek k—A _ City+ `^ Lot Size PM L 1 f��L (�� i�aV I Address :I 'll` �/ e�'T� _ Phone � L 63 6- Owner's Name ll ��1? t T �!f lq� Ai:13 se'�r t1- Y c� License.No.c-Z� 3 Phone k Contractor _ _ TYPE OF WELL/PUMP" � NEVIWWELL WELL REPLACEMEN_T� _ ^'DESTRUCTION { 1P[1MP INSTALLATION SYSTEM RE?.AIR ❑ `rf � ; OTHER ❑ DISTANCE TO NEAREST zSEPTIC TANK S D .'SEWER LINES £ ,D(SPOSAL FLD. PROP. LINE `T;-/ FOUNDATION- AGRICULTURE WELL OTHER WELL-- S � PITS/SUMPSA� / INTENDED�USE/ TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial , Open Bottom ❑ Manteca, Dia.-of Well Excavation Dia. of Well Casing c� omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing +P F Specifications M Public �7 y�❑ Other n Delta Depth ofyGrout Seal �~ ,ype-of tout I 1 Irrigation. c�✓�..Approx. Depth l I Eastern / Surface Seal Installed by ?"V �1 �' h r� -- Repair Work Done ❑ Type of Pump N.P. /: State k Done .� Well Destruction ` Well Diameter -1 - Sealing Material (top 50'1 _C �rn-A�� Depth ��., Filler Material I$eiow 50'I - ( TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I 1 DESTRUCTION l 1 INo septic system permitted if public sewer is O available within 200 feet.l i I Installation will serve: Resilience Commercial__ Other _ ( Number of living units: - Number-of bdooms Character of soil to a depth of 3 feet: `' " Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑F Method of Disposal r Distance to nearest: Well Foundations Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lin e�""�.. SEEPAGE PITS I I Depth Size'' Number ` SUMPS Lel 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 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:-. k 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 iK the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-tion laws of California." rS The applicant must callforall required inspections. Complete,drawing on reverse sidle. Signed X j} / / a,-1!V Title: �f�/ A IP�C� Date: F1 I FOR DEPARTMENT USE ONLY ! f Application Accepted byDate v Area-12— Pit of Grout Inspection by`� JJ i Date Final inspection by Date -7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 F Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .tf . E � FEE AMOUNT UE..... AMOUNT REMITTED CK RECEIVED_BY,�, —DATE,. P,ERMIi NO., -- - �---- -^�. .CASH �.-- _ +.EH 1 .24 1AEY.r/n 51 /U %�� i EH 144-28 ! / v