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/el ti {, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED may, 1 mplete in Triplicate) cr--l2�J „d3 MCS est�C7'�l`r[;0 f{ E?_S E xzcjli Application is hereby made to the San Joaquin local Health istrict 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. �5dK 5 l Job Address A) -6- alk,5f& I�� j City Lot Size PM / (�� Owner's Name if, &246? Address �4 A^IIc�I,tldO� �ly� /j� Phone 30 � 9'7.. 1 Contractor_ifj� Address/'� 110�i License No. TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ -WD'ESTRUCTION — k th ` PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER 5 ' "1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ C, INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS `' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ t Well DestructionA Well Diameter 2-01-6k, Sealing Material (top 501 �rt n f..t.k I Depth {.3 Ff Filler Material Ieelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i_I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial .�" Other ' 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation— Property Line � � r i SEEPAGE PITS C I Depth Size Number i SUMPS ❑ Distance to nearest: Weil Foundation Property Line j DISPOSAL PONDS ❑ Y� 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 r 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 r L 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 at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws Q; a i or The applicant s f all quired inspections. Complete drawing reverse side. Signed X Title: <r " Date:ftr FOR D ARTMENT USE ONLY ; Application Accepted by Date Area G Pit or Grout Inspection by Date Final Inspection by nn Date�s ��42 , Additional Comments: 061 �Wr ❑ 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 AMOUNT REMITTED RECEIVED BY DATE PERM47'No. INFO ASN r + EH14-24 IREV.s i x s7 fa� D EH 14-26 i