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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT C 1601 E. HAZE T ON AVE., STOCKTON, CA ��vr �`' 72 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' f (Complete in Triplicate) :dtion 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 .ue in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin ,ocal Health District. k= Job Address !V - 1,4'r N L _ City Lot Size' !R tI&f PM r Owner's Name ! ran S Ad reqs Phone d3ll�ireA f/�Contractor ss fo License No.,0779-1 Pho 707 �7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 5' 7-y j"cA,a Lved DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE FOUNDATION 7rQ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION a ' J9 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing 10 t I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing IIC- 5� Specifications M Public f_-i Other F1 Delta Depth of Grout Seal Type of Grout_62m�_. i l I f Irrigation 3a�-Approx. Depth ( ] Eastern Surface Seal Installed by r',� mnet ti r '� _ Repair Work Done ❑ Type of Pump H.P. Statd'Work Done 'Well Destruction ❑ Well Diameter Sealing Material (top 50') �e Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l 1 INo 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 g Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ff SEEPAGE PITS [ I Depth Size _ Number I SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Dibtrict. 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." 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 employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse s' /C? Signed X '� ler^ t/, SGfFC� Date: 0 1 1 I r FOR DEPARTMENT USE ONLY ! Application Accepted by a Date C QArea PitGro Inspection by Date d Final Inspection by �'��J` Date I S Additional Comments: r 71'1 739��'te ' �m El 466 6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 �lsv►r'rrc r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE Saer � INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. + EH 14-24IREV.4/H51 7OE 40 EH 14-24 �'r 1 U L v v-'C—,Z t� r