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.fes it L�I APPLICATION.FOR PERMIT I. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA "' M '-Telephone (209) 466-6781' PERMIT EXPIRES 1 YEAR FROM"DATE ISSUED .. ,(Complete in Triplicate) r + •., :; � 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. �Si r, Job Address jJ r .Cit _ Lot Si P 'Owner's Nam Address �+�t 1 `-u' - Phone v� mm Contrac� Address 't-54 License Na �aa� Phon �d S`� TYPE OF WELL/PUMP: 4 t NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP"INSTALLATION ❑ "SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r ❑ Irrigation --L-Approx, Depth ❑ Eastern Surface Seal Installed by -,£ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 501 s*1y Depth Filler Material (Below 50') }, TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is e ` I i II available within 200 feet.) $ + Installation will serve: Residence V Commercial Other l Number of living units: l �i 'Number of b drooms t� Character of soil to a depth of 3 feet: Water table depth Q f .. —W TANK L Type/Mfg ' Ca.pa-it y-- SEPTICZs?G9C):��N Compartments PKG.t TREATMENT PLT. ❑ 1i �, rte_._ y fes !v.—-Method of Disposal Distance to nearest: Well Foundation/ Property Line LEACHING LINE CfJo. & Length of lines —µ r ; Total length9size7 X FILTER BED ❑ Distance to nearest- Well-J a Foundation_"�/Q Property Line f SEERAGE PITS Depth W Size Number ' SUMPS El_- Distance to nearest: Well �sw7, Foundation �l� ( Property Line r... a' DISPOSAL PONDS ❑ 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 "- F Y performance of the work for which this permit is issued, I shall not 4 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: "I certify that in the performance of the work for which this permit is issued, I shall emas ploy persons subject to workman's compensa tion laws of California." [ The applicant mu "call for all r ed inspections. Complete drawing on reverseXP I Signed X Title: Date: " --- -,FOR;DEP.ARTMENT USE.ONLY •-.-. Application Accepted by \\_ 1"Date f, I Y Area A I Grout Ins C7 or" Inspection by y _ ate_ _Fina(Inspectionon_b _-- _._ Y - —Date•- Iool Additional Comments: 1a ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201` ' ,l. FEE u INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEt PERMIT"NO. + EH 1 -24IRE V.i/H51 f1-()a F--7 EH 144-28 LJ' 1 gar Ili