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a } Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. } Job Address 5-d' e 14-Y 73 fr7' City rYWf!�. Lot Size PM Owner's Name *Q Address Phone F Contractor /Y�JC �7A� Address X&-2 14�'° N License No. � Phone_ z TYPE OF WELL/PUMP: NEW WELLC7 _ WELL REPLACEMENT El DESTRUCTION ❑ -- ^PUMP•INSTALLATION'0 ^� SYSTEM-REPAIR-p---- OTHER-❑ �"_ _ �._.�a.. DISTANCE TO NEAREST: SEPTIC TANK J _SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION 1 AGRICULTURE WELL T J0THER WELL PITS/SUMPS INTENDED USES TYPE OF ''ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial a0 ❑'Open Bottom ❑ Manteca Dia. of Well Excavation s Dia. of Well Casing '7 F• EJ Domestic/Private! � ❑ Gravel Pack ❑ Tracy Type of Casing - I Specifications l'1 pt,btic"' ` '" ❑mother Cl Delta ,=,Depth,of Grout Seal Type of Grout q f 1 1 Irri ation -Approx. Depth I 1 Eastern , Surface.Saul Installed by ti_1 b Repair Work Done LJType of Pump H.P. State Work Done _ C WellDestruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 € TYPE OF SEPTIC WORK:; NEW INSTALLATION I1 REPAIR 1ADOITIO - DESTRUCTION I i INo septic system permitted if public sewer is ! available within 200 feet.), Inst Ilation will serve: Residence/1 Commercial— Other I Number of living units: Numbet of bedrooms A�e r - V Character of soil to'a depth of 3 feet:- f� A11 Water table depth 'SEPTIC TANK e Type/Mfg A° G Capacity-1900 No. Compartments ' P,KG TREATMENT PLT. ❑'� Method of Disposal I Distance to nearest: Well Foundation Property Line EAGHING LINEr+ CI 1No. & Length of lines Total length/size FILTER BED x '.❑ Distancelto nearest: Well Foundation Property Line SEEPAGE PITS l I ;,Depth Size l�`' u bar SUMPS � �Disfance to nearest: Well T Foundation Property Line. _ , DISPOSAL PONDS ❑ k, ! tf.-.- 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 rulesr,and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signaiure 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 issued, 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 X_FI` 1�7 f�G ' Title: Date: F EPARTMENT USE ONLY /f f Application Accepted by Date ef Area Pit or Grout Inspection by t Date Final Inspection by Date Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 i� FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO + EH 1324(JEV.1 i H 5) '� totQ w al EH 14-26 1 X