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x, APPLICATION FOR PERMIT iP►Y En r SAN JOAQUIN LOCAL HEALTH DISTRICT REC��V 1601.E. HAZELTON AVE,' STOCKTON, CA �g�g i Telephone (209) 466-6781 V_8 ?I � IPERMIT 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 Ryles and Regulations of the San Joaquin Local Health District. " w :It ,. Job Address ' D 1 �, P _ Crty Lot Size 'r PM w Owner's Name Addressi /Yl�'��__�, A I —{� Phoneme" r - Contractor g Address � License No _�v- 26% g Phone-2- TYPE OF WELL/PUMP: NEW WELL J& WELL REPLACEMENT Q DESTRUCTION ❑ F _ _ PUMP INSTALLATION jt _ SYSTEM REPAIR ❑ __ OTHER EJDISTANCE TO NEAREST: SEPTIC TANK'- . SEWER LfNES�'�` DISPOSAL FLD, PROP.LINE'-' FOUNDATIONt 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 Domestic/Private ❑ Grav?l Pack ❑ Tracy Type of Casing 11 Public Specifications ❑ Other. ❑ Delta Depth of Grout Seal L2 Irrigation _,A t Type Grout i pprox. Depth ❑ Eastern Surface Seal Installed by ! Repair Work Done ❑ Type of'Pum 3 yP p H.P.L�/_z_ State Work Done ' Well Destruction ❑ Well Diameter I Sealing Material {top 501 Depth I Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is € r available within 200 feet.) Installation will serve: Residency_ Commercial— Other._,_ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth g -�Ca SEPTIC TANK ElType%Mf � � , "acii ' - p ty No. Compartments r PKG. TREATMENT PLT. ❑ —�" `' --- Method-of-Disposal Distance Distance to nearest; Well Foundation t property Line' i Property {i ce I� LEACHING-LINE ❑ No. & Length+of linesTotal lengih/size ► ��i FILTER BECO LJDistarlce'to nearest:-'~ 1/Vall A Foundation Property Line SEEPAGE PITS ❑ DepthSizeJ� _ Number t I i SUMPS ❑ Distance to Weare _ip Well 'J �"+yFoundation - _ Property Line -- _ DISPOSAL PONDS ❑ r'.. :J - 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." Contractors hiring or sub-contracting signature r 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. I The applicant m st c I fo all equired inspections. Complete drawing on r erre side. Signed Title: Date: t R I FO DEPARTMENT USE ONLY Application Accepted by - _� Date Area ' ..� t Pit or Grout Inspection by Date Final Inspection'by Date 4! f' Additional Comments: *� ❑ Stk 466-6781 ❑ Lodi 369-3621 M ❑ Manteca 823-7104 " ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I� INFO AMOUNT DUE F� AMOUNT REMITTED RECEIVED BY DATE PERENO,, " T *EH 13.24(REV.r/a 5) ei -��y y EH 14-26 � e` I1 y _ r y