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i i k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE.,STOCKTON, CA i t Telephone (209) 466-6781 N IPERMIT EXPIRES 1'YEAR'FROM DATE ISSUED" ' y (Complete'in Tripikate) ' 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 Ryles and Regulations of the San Joaquin Local Health District. w {+ w �. -[i Ill _. r � •.F "t '' Job Address — � �., . 3S" City eyL Lot-SizepM Owner's Name d 4 Phone Adi•ess^�''-F --- -- 9t.,Z� Contractor Address i - License Not Phone T b 6? l� TYPE OF WELL/PUMP:' 'NEW WELL ❑, ti- WELL REPLACEMENT L7 DESTRUCTION ❑ PUMP INSTALLATION ED iI t-< SYSTEM REPAIR .❑ OTHER ❑ +� "tSEvyER\LINES t ti �� DISTANCE T,0 NEAREST: SEPTIC TANK ; }�t _DISPOSAL FLD. PROP. LINE + vL FOUNDATION! _p;GRIEULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONPS PS ECIFICATIONS I ❑ Industrial ❑ Open Bottom—ED—Manteca—)Dia. of Well.Excavation Dia. of Well Casing 1 4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing s' i�' ? Specifications ; D Public D-Other-r EJ Delta, Depth of Grout Seal # p - - Type of Grout ❑ Irrigation `._�4pprox. De th ❑O< �` `R ` Depth Eastern Surface•Seal-Installed by = Repair Work Done "L 1 Ll of Pump H.P. j Staie-Work potfne i Well Destruction ❑ Well diameter Sealing Material Depth t ""°F """"'--Fiiieer19 laten5Ij13''I6TW50'1 l �' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 'DESTRUCTION ❑ iNo'septic system permitted if public-sewer iso, „available within 20.0 feet.) ` Installation will serve: Residence Commercial_,Other i %+i -`, w Number of living units:__/.- Number of_be Character of soil to a depth.of-3-feet: D Water table depth Ups # SEPtIC TANK r- Type/Mfg-`. -',,l R Capacity No. Compartments . PKG! TREATMENT PLT. ❑ f ` Method of Disposal Distance to nearest: �..% .w-_ _ 1 p .-�•--Well' Foundat[on �-•--- Property Line ` LEACHING LINE No. & Length of lines~ �' �' ! Total length/size a FILTER x.11-� 1-1st Distance to neare • "'Well �QO s Foundation"/� it`?- Property Line SEEPAGE PITS Depth F` �' "Bike. !/ i j —!*-Found Number ,SUMPS ❑ distance to nearest: Well L H+'7ation-.-/d f Property Line_. r DISPOSAL PONDS {❑ _. : r j a I hereby certify that I have prepared this application and that the work will Abe done in accordance with San Joaquin county ordinances, state'laws, and� 'rules and regulations of the San Joaquin Local Health District. •t i rr e ,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-shelf not employ any person in such manner as to become sutijddl to workman's compensation law's of California." Contractor's hiring orsulrcontracting signature ' certifies the following:"I certify that in the performanee`:of the work far wWh.this permlt•is`issued, I shall:employ persons sub act to workman's c-om ansa=. _ 1 R t.tion laws of California." ' •' �G _ .. > ;• l 't , _ y �'The applicant m call for a I equir [ specti Comp to drawing on rave se side. 1 ~N I Signed % FFA Title: Date: P (` FOR DEARTME T USE ONLY f r - Application-Accepted-by `-- � - -•�--cDate — - a_.� _ I I[ Pit or Grout Inspection by Dated Final Inspection by f�Jr� Date ' Additional Comments: t�� ., ; 3 I ❑ Stk 46&-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r INFO AMOUNT DUE I. AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'N0. + EH 13-24(REV.1/B5) EH 10.26 LA S" 0