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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA j Telephone (209) 466-6781 1 PERMIT EXPIRES'TYEAR 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 l Local Health District. rL . S City , cr I.-,t Size / — PM Job Address k n �.. �1 , / ( � 0 aqf e-�Ic�G Owner's Name e � Address ¢ Contractor�� 7t Address�z% �! !v'GZ License No.L �l _ Phvne1 ` (� TYPE_OF WELLIPUMP_: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION�f,, �►.] i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ a�—y-OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL-777-1�r OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.�of ❑ Industrial El Open Bottomt]-Manteca Dia. of Well Excavation Well Casing ❑ Domestic/Private ❑ Gravel P_aek ❑ Tracy Type of Casing Specifications [']'Public El`Other F1 Delta Depth of Grout Seal Type of Grout - I E Irrigation Approxi Depth I 1 Eastern Surface Seal Installed by - r Repair WoF(c Done ElType of Pum`p H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth `1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INST LLATION Ivf' REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is ravailable within 200 feet.) B Installation will serve. Residence°. Commercial's Other— Number ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet'l C-,7` Ao4 !!// Water table depth SEPTIC TANK ❑ Type/Mfg! Capacity "-No. Compartments PKG. TREATMENT PLT. Er � I Method of Disposal I Distance,to nearest: = Well Foundation �7/V - Property Line Sy W —,e sc, TC-ifs A, [ c i�J Total l n ? LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance'fo nearest: 1Ve11' Foundation Property Line L a # SEEPAGE PITS 'i`I .Depth Size Number y_ - • SUMPS Ll Distance to nearest: Well Foundation Property Line 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 i 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, l shah 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 st callr all it rnspec ions. Complete drawing on reverse side. Signed Title: N Date: 4 FOR DEPARTMENT USE ONLY I Date !{l Area i Application Accepted by n, l k Pit'or Grout Inspection by Date Final Inspection by y ' ��" Data-� Additional Comments. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 623-7104 [Macy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95241 I FEEjAMOLUINT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + ER 13-24 24 IREV:t i H S) - ® '��l` r O (! 7� F