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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 `PPERMIT EXPIRES 1 YEAR FROM DATE ISSUED [� NC (Complete in Triplicate) Application is hereby made tote Joaquin San Joa uin Local Health District for a permit to construct and/or install the woV e m scrr d. This applicatio is c 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. �j K Job Address 5 ✓ a ✓ --6 0, 444 City Lot Size PM — Owner's M Owner's Name �Oda Address Phone I. w fiA54-bi Contractor - Address ,•0' License Noll &0 Phone MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ..TYPE OF WELL/PUMP: • PUMP INSTALLATION ❑ 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 r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications n h Ll Public ❑ Other A Cl Delta Depth of Grout Seal Type of Grout = I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by p ' Repair Work Done ,❑ Type of Pumpt H.P. State Work Done_ N Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION,t I, DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.( Installation will serve: Residence�'—C�ffeYat_" Ot1te7 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. Compartments PKG. TREATMENT PLT. ❑ _ _ 1 Method of Disposal ; Distance tolnearest: Well --Foundation Property Line k LEACHING LINE ❑ No. & Length of lines Total length%size FILTER BED ❑ Distance tonearest: Weil Foundation Property Line SEEPAGE PITS I'I Depth Size .k Number SUMPS ❑ Distance to,,nearest: . Well Foundation Property Line DISPOSAL PONDS ❑ r 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 c3ert, -_ify that in he performance of thelwork for which this permit is issued, I shall not employ any persoaii ner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature �,t certifies the followthat in the performance of the work for which this permit is issued, I shall a ploy persons subject to workman's compensa- tion laws of Cali g3 The applicant muequired inspections. Complete drawing on reverse side. Signed X Title: UW 004.1!' Date: ~ FORTMENT USE ONLY — ' 1.. Application Accepted by _ Date .Area 77 Pit or Grout Inspection by / + Date Final Inspection by_ Date / Additional Comments: F 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 FEE AMOUNT DUE r AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMiT'NO. INFO + EH 13-24 IREV.i i n s) � CkA EH 1428 ttt 1111 _ i