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APPLICATION,FOR PERMIT I x, i SAN JOAQUIN;LOCAL:HEALTH DISTRICT 1601 E..HAZELTON-AVE., STOCKTON, CA T`e'lephone (209)466_6791. PERMIT EXPIRES.1 YEAR FROM ,DATt.ISSUED.:. ,e odS 'z eE(%w8 ".ij '. 1 'zi' �€ 1 i,e.'ds�1€ �'!3`ri (Complete in Triplicate) eai ' sa• r 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#or.'sewage,or Now 1W2 for well/pump-and the-Ruies-and Regulations of the San Joaquin Local Health District v + ;s. •.RNs _ �n1f) I'=flln,l.11.' " ' Y: :i r' :If) :; -i�lr .rt r�y,gli% �{1. Job Address city = --Lot Size PM Address 5A^7G Phone f Contractor's Name ' /E 194K 712&X: / '�'N License No. yfy 9/ Phone 5:z3 zf 0, (TYPE"OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK. SEWER LINESDISPOSAL FLO. PROP. LINE ' FOUNDATION AGRICULTUREWELL I OTHER WELL _ PITS/SUMPS j INTENDED USE TYPE OF WELL' :PROBLEM AREA -CONSTRUCTION,SPECIFICATIONS ❑ Industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications k❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation t �. g � ... —Approx. Depth� ❑ Eastern Surface Seal Installed-by Repair Work Done ❑ Type,of Pump H.P. State Work Done Well Destruction ❑ Well-,Diameter Sealing Material (top 50') Depth Filler Material (Below 501 '+ .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 Other - - - _ . Number of living units: IVumbe�ofbedrooms Character of soil to a depth'of 3.feet: -5��1� aAl" Water table depth -.SEPTIC TANK ® Type Mfg Y - _ Ca actty /R o No. Compartments �- PKG. TREATMENT:PLT. ❑ _ . .._ _ T Method of Disposal m= Distance to nearest: jWell «.5` Foundation /a Property Line ;Z t LEACHING LINE No. & Length of lines 3 8h' F. Total length/size i" FILTER,BED ❑ ;Distance to nearest: Well. - Foundation �S Property Line SEEPAGE PITS ❑ ':.Depth Size. I Number SUMPS ❑ Dista nce to nearest:" Well - Foundation Property Line # DISPOSAL PONDS ' ❑ I' 1 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. - - • .... + i - 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 in the performance of the work for which-this permit is issifezl'I'shall employ persons subject to workman's compensa- ..tion'laws of California." -, The applicant must call for all required inspections. Complete drawing on reverse side. Signed �['l/!1/. tli Title: Date: .. �. ._ 1 F Application ONLY ,- . . FOR DEPARTMENT O D T USE NLY n Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by _ T C!Additional Comments: t �r !, • N "i'❑ Stk' 466-67$1'-L- ❑ Lodi- 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 — Applicant- Return all copies to-' Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 r AMOUNT DUE ' AMOUNT REMITTED CK* RECEIVEDBY 'INFO CASH LATE PERMIT"N0. t y '+ EH X15-24(REV.10l83I F ( L +,/ 1� � .t ., __ ,r t5- •.` i�; y =5-y-S.3- �s- 11,91 f EH 1426., i