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i a A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT A_1" 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-51$1 Grit ` PERMIT 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 Rules and Regulations of the San Joaquin Local Health District. 944 I, �vS� Job Address t �2 City �✓ Lot Size PM s G Owner's Name k[At: Address 13-29 L [•JAS Dese Phone939 _ Contractor's Name � License No. Phone TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT If DESTRUCTION ❑ -.Z4 PUMP-INSTALLATION.3!( SYSTEM REPAIR ❑ OTHER ❑ 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 SPECIFICATIONS ❑ industrial E3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public C Other ❑ Delta Depth of Grout Seal' Type of Grout ❑ Irrigation ---Approx. Dept ❑ Eastern Surface Seal Installed by Repair Work Done 'S1 Type of Pump H.P. State Work Done WeltDestruction-...,,,,0_Weil_Diameter_ —Sealing Material-(top 50')•- r Depth Filler Material (Below 501 '& c TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DEST CTION ❑ (No septic system permitted if public sewer is AJ&t L .!.,v 11 ? available within 200 feet.) Installation will serve: Residence_ Commercial Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water.table depth SEPTIC TANK ❑ Type/Mfg Capacity 'No CCompartments PKG. TREATMENT PLT. ❑ Method of Disposal . Distance to nearest: Well Foundation Property Line . LEACHING LINE ❑ No. & Length of lines Total length/size + ` �v FILTER BED ❑ Distance to nearest: Well Foundation :Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL..PONOS ❑ hereby certify that I have preparedthis;application andthat 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. "# s ! s IL Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the Work for whi6K this'pertnit 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 certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa tion laws of California." The applicant call for all requi a inspecons. Complete drawing on rev rse side. i Signed X Title: i Date: �✓ E FOR DEPART ENT USE ONLY xA ;Application Accepted by ZDate � Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: V; � } , ! f• ❑ 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 M l JATIV13MORIVIV113 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. (NFO CASH a Ex 13-24(REV.101831 � 1y,1, EH 1428