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APPLICATION FOR PERMIT SAN JOAQUIN .LOCAL HEALTH,,DISTRICT F r 1601 E. HAZE T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 ! PERMIT EXPIRES 'I YEAR FROM DATE ISSUEDvq Y , ;.. (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 f made in compliance with San Joaquinl County Ordinance No.549 for sewage or No..1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 r Cit C..! t Lot Size •• PM Job Address Y Owner's Name0A'2i)'yD✓C Address Phone ContractorAddress ?d z License No. �1 � 6�/�cT� � Phone TYPE OF WELL'/PUMP: INEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j ' PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION ._ AGRICULTURE WELL OTHER WELL PITS%SUMPS INTENDED USE TYPE'OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS` ❑•Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . i ❑ Domestic/Pri`vate ❑ Gravel Pack 1-1 Tracy Type of Casing Specifications ❑ Public i ❑ Other ❑ Delta Depth of Grout Seal Type of.Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal 5Installed-by E1 Repair Work Done ❑ Type of Pump H.P. � ` j � State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 I } I TYPE OF,SEP:rx WORK: NEW INSTALLATION , EPAIR/ADDITION.❑ DESTRUCTION ED] [No septic system permitted if public sewer is w ,'jam l ,• &#` available within 200 feet.) Installation will serve. Residence Commercial_ Other ; '._ Number of living units: __/__ Number of bedroorlts r` i �1 �• {er) Character of sb it to a depth.of 3 feet! A �A R c t Water table depth; SEPTIC TANK ❑ T r ype/Mfg �� Capacity. No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal I t Distance.to nearest: Well Foundation_'.CO Property Line S �/•� '": i V LEACHING LINE �No. & Length_-of lines-, ' V-t d'D :_- Tofal'length/size I. FILTER'BED ❑ -Distance,to nearest: Well Founf�lati4�Property Line �0_.__.__._.._� P 61 SEEPAGE PITS I ❑ Depth Size 1' Number ) r SUMPS i ❑ Distance to nearest: WeltFoundation -Property Line s r DISPOSAL PONDS ❑ t,- 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: "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 subcontracting signature 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." 4 r r The applicant.must call for I1.requ d inspections. Complete drawing on reverse side. i '1 Signed X 3�� --- ---tfitle: �t'��c.e.[w�——f Date: -. FOR' EPARTMENT, USE ONLY Application Accepted by CA VL —Date Area Pit or Grout Inspection by t Date ti Final Inspection by Date 6 Additional.Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 ! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E:Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IN. —AMOUNT-DUE' ACK MOUNT-REMITTED CASH RECEIVED BY DATE PERMIT NO. kt •��EH 13-24 IRfV.