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4� APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT r , 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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/pump and the Rules and Regulations of the San Joaquin Local Health District. i ^ Job Address I 100 � Cii Lot Size __ PM Owner's Name' + - AddressPhone + 03 ContractA.';r + JA` lit Address Vn �M�7 License No 2 2 z Phone 0-S-1101-7 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 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I-) Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia- of Well Casing ❑ Domestic/Private - El Gravel Pack El Tracy ; a, ' Type of Casing Speci#i�earons ' 1-tPublic !7 Other _ 71 Delta r Depth of GrouC Seal Typ ;of'Grout ` 1 1 Irrigation .-Approx. DepthI I Eastern Surface Seal Installed by� Repair Work Done ❑ Type of Pump Pf:P.. r State Work Done a t Well Destruction ❑ Well Diameter Sealing Material-(top 50'1 ' I Depth ler Material IBelow 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR ADDITION DESTRUCTION I k 1No septic system permitted if public sewer is 0 va'1 ble within-200 feet.) i Installation will serve: Residence Commercial —Y, Othe r Number of living units: Number f bedroo s O Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg �� i Capacity- `ASOO No. Compartments PKG. TREATMENT PLT. 0 { Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ , Distance to nearest: Well Foundation Property Line SEEPAGE PITS '•Depth 9 5L Size, _- —r— )lumber ' r T SUMPS ❑ Distance to nearest: WellE sn Foundation C150+ Property Line LL 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, andY rules and regulations of the San Joaquin Local Health District. J Home owner or licensed agent's signature certifies 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 it the performance of the work for which-this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m call for all a uirAd inspections. Complete drawing on reverse s e. Signed X _ •, Title: ' - Y Data: - I � � FOR DEPARTMENT USE ONLY Application, by / f +� °�� !,Dated_ Q � Area / &or Grout.lnspection by f ate f Final Inspection byL/ / .fir spate tel Y 'Additional Comments:!'' E C3%Stk 466-6781 , ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 y Applicant Il eturn'all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95241 t< l•FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT'NO. rte INFOr - _CASH EH 14-26 1 `` !!! +.EH 13-24/REV.{/H b) S K + (� !� ,ql ��