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- . APPLICATION FOR PERMIT1 �/{^ - SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZEL 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. 16 7A _jt, r �f�l� 1 Job Address City 1-061; Lot Size '�-)' PM Owner's Nameh'>rress 1617 O AL �� _ Phone Contractor's Name License No. -2-,111 15,7 Phone ,S;TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ - — -SYSTEM`REPAIR'❑' OTHER-t J= 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 SPECIFICiATIONS 1l;, i ❑ Industrial XOpen Bottom= ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing pia F ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__._..__s4A..1 Specifications ❑ Public ❑ Other ❑'Delta.,,.»---_-_ Depth of Grout Seal f Type of Grout irrigation ---Approx. Depth ❑ Eastern 1 Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.r_!' .'a State Work Don Well Destruction ❑ Well Diameter Sealing Materi op 50'i Depth Filler Materi ('Below 50'1 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____ Commercial— Ofher Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg caps tty�__ d:`Gompartments { PKG. TREATMENT PLT. 71i` Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ! `i Total length/size FILTER BED ❑ Distance to nearest: Well j Foundaton. �`" Property Line ",SEEPAGE PITS ❑ Depth Size I s Number SUMPS y ❑ Distance to nearest: Well Foundation Property Line ~ r r DISPOSAL PONDS F1 -{ 41 hereby"certify thaf I have prepared this.application and that the work will be done tri accordance with San Joaquin county ordinances, state laws, and rules,and regulations of the San Joaquiii-Local Health-District:------�--- - --� Homeowner or licaNsed 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 tc'6ecome subject to workman's compensation laws of Cal'iforn'ipp."Contractors hiring or sub-contracting signature certifies the following: "1 certify that in the•performahce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califor ia." . r. �; l 11 The applicant m require insp�c omplete drawing on revew sidg. { Signed ' _t " u Title: i ' Date: /_ f FOR DEPARTMENT USE ONLY Application Accepted by Date 3 Area Pit Grout Ins ction by Date Final Inspection by Date i 9. Additional Comments: 0 ❑ Stk 466-6781 ❑ Lodi 3813621 ❑ Manteca 823 104 ❑ racy ,f`�,� Ih Fr,,,, ,)� Applicant- Return all copies to: Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 `� i�� y r,v&e-A cvz s $-o,' -rJu�CK S 1"� irEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. �/wl EH 1 -24(REV.10183E 00 _.��J EH 14-26 LLL �' / f