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� a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Jab Address �Y / %`�7 ��t[� /l��i r� City Lot Size �'t PM Owner's Namass hone �J` 29 Contractor's NameW_&W1&Xn.e No LQ�J - �� Phone � •-' Y TYPE OF WELL/PUMP: NEW WELL �k %%,ZELL REPLACEMENT DESTRUCTION 1:1 PfUMP INSTAL' TION ] YSTE REPAIR ❑ ��77O�TTHT�R ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.J� PROP. LINE / „��-- FOUNDATION 1 AGRICULTURE WELL �, OTHER WELL— PITS/SUMPS INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 13 Open Bottom ❑ Manteca Dia. of Well Excavaiion Dia. of Well Casing 'Domestic/Private 4 vel Pack!_..„ _❑ Tracy Type of Casing �,TF"�,L Specifications �� ? i ❑ Public �,OtGra her ❑ Delta Depth of Grout Sea] {J r Type of Grouv Al ❑ Irrigation -L�__Approx. Depth ❑ Eastern Surface Seal Installed by 1 - NJ I Repair Work Done ❑ Type of Pump H.P. State Work Done - Well Destruction ❑ Well Diameter Sealing Material (top 501 ' tt' (/ Depth- Filler Material (Below 50'1 'f J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is IIavailable within 200 feet.) r Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms__Y-- �_ �� _ Character of soil to a depth of 3 feet: t Water table depth r� Capaci No. Compartments V 'E SEPTIC TANK ❑ Type/Mfg f r'. tY � . PKG. TREATMENT PLT. ❑ i Method of Disposal Distance ro}nearest: Well Foundation Property Line j LEACHING LINE L1No. & Lengi~.th of lines Total length/size . FILTER BED ❑ Distance to nearest: Well Foundation — - Property Line / 1 SEEPAGE PITS -'❑ Depth Size Number l� SUMPS ❑ Distance.to nearest: Well Foundation Property Line DISPOSAL PONDS w 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 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 mmTTaT for all required ins ct, ns. Complet rawing on reverse side. Signed Title: ^ V1 L' ` — Date: f FOR DEPARTMENT USE ONLY Q Application Accepted by Wy rDate v Area / Date anpection b` bate Pit or Grout Inspection by F' l Is 4 , Additional Comments: ❑,Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I l FEE AMOUNT DUE .� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO 8g �i1 +EH 1&24 fREV.10!831 vy G �.J �p ` �y I� EH 1426 it O