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s"- °✓ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETOWAVE., STOCKTON, CA Telephone (209) 466-6781 }V -PERMIT EXPIRES 1'YEAR FROM DATE ISSUED P � (Complete in T iplicate) Application is hereby made to the San Joaquin Local Heath District for a permit to construct and/or install the work herein described. This application is made in compliance with San Jd�equin County Ordinance No. 549 for sewage'or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District t1�1� a �r C u ��Q ." / L r 7J ' OQ� 12 O +l AJ Job Address , V i City 6OWLot Size PM I' I 1�I Address / ��J� / ""'�'G � Phone Owner's Name Contractor Address e cense No. Phone TYPE OF WFLL7.PUMP: I�' NEW WELL i WELL REPLACEMENT ❑ DESTRUCTION ❑ � -PUMP INSTALLATION Lel/ SYSTEM.REPAIR ❑ OTHER ❑ :0 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 SPECIFICATIO S G !� ❑ Ind I open Bottom C] Manteca Dia. of Well Excavation _ _[N1 Dia. of Well Casing {} a omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - —4pe_I Specifications C Afi FI Public ❑ 0;1er F] Delta Depth of Grout SealEW_ of Grout ��1�' I I Irrigation .Approx. Depth I 1 Eastern Surface Seal Installed by DQI l EW_ �^ Repair Work Done ❑ Type of Pump 's)� H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material IBelow 50') OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted it public sewer is available within 200 feet.) i t I Installation will Residence Commercial Other Number of living units: umber of bedrooms.— iv edrooms. 1 r Water table depth f Character of soil to a depth l�f 3 feet: SEPTIC TANK ❑ iType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ '1, Method of Disposal !'Distance to nearest: Well dation Property Line t r 'I� it LEACHING LINE ❑ No- & Length of lines ngth/size r FILTER BED ❑ ''Distance to nearest: Well Foundation Prop �in F SEEPAGE PITS 1-1 :Depth Size Number f SUMPS LlkDistance to nearest: Well Foundation Property Line r +l 1 s DISPOSAL PONDS ❑ r 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, ane 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 sub contracting signature certifies the following: "1 certify that in the performance of the work for wt}ich this permit is"issued, I shall employ persons subject to workman's compensa` tion laws of California." I�I �•s { The applicant st c I r all required in ction Complete drawing on reverse side. Signed X Title: " Dater_ �'�� Il _, _• - FOR pEPARTMIENT USE ONLY l Application Accepted by Date Area / i Pit or Grout Inspection by I� Dategq--146_IFinal Inspection by Date off' z- ? Additional Comments. f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8237.7104 x ❑ Tracy 835-6385. Applicant - Return all copies to: Environmental HealtWPermit/Sdrvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH _ RECEIVED BY DATE fP�ECR]MIT'NtO1. ♦ EH 13-24(Rev.t/H 5) O V /r�"} E �S ^ /�� j •l�T�