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ve& r - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 2 332x'"it/ a- f=ftl�� Ji4 , ��' (Complete in Triplicate) Application is hereby made to the San J aquin 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 fpr well/pum aid the Rules and R gulations of the San aquin Local Health District. � _ f �JiGT�Q /�ip�jE/�►,�f 1_1� /��' �� YP Jab AddressVIAIJECity L t Size b kV4FM r . .O Owner's Name " i_ HEOLddress Phon t pLt:7 Contractee /f/ C. dress License N1379-7 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION., SYSTEM REPAIR El i .:.OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK '°'SEWER LINES ti sDISPOSAL FLD. PROP. LINE FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '111Industrial El Open Bottom ❑ Manteca .r - Dia`. of Wel{ Exc/a/Yationn Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ¢ ` Tracy, _., Type of CasingSpecifications F] Public [-1 Other C] Delta W1, Depth of Grout Seal Type of Grout _ irrigation �_..Approx. D I Eastern Surface Seal Installed by. Repair Work.Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 501 Depth I _-_Filler.Material,(Below 50') " TYPE OF,SEPTIC WORK: 'NEW'1NSTALLATION I ] REPAIR/ADDITION l 1[ DESTRUCTION t I (No septic system permitted if public sewer is F available within 200 feet.)' Installation will serve:,Residence_ _Commercial Other y -Number of living units: Number of bedrooms Q s 3> „C12aracter of.soil to a depth of 3 feet - Water table depth r.` SEPTIC TANK ❑ Type/Mfg Capacity ° No. Compartments PKG. TREATMENT, T. ❑'i`., ' Method of Disposal Distance to nearest: Well Foundation ' " `Property,Lins LEACHING LINE ❑ No. & Length of lines9` h.. � Notal len1gth/sizAe 'FILTERBED-�'—[D7 ' Distance-to.nearest:""""'Well'""`''^"""—Foundation—""":F—Property'Line ro SEEPAGE PITS l I Depth I Size Number SUMPS C1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 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 f all required inspections. Complete drawing on r verse side. 'y ,r Signed l Title: Date: FOR DEPARTMENT USE ONLY _ f Application Accepted by 6 �. ___ Date Area Pit or Grout Inspection by Date Final Inspection by ` DateV.Z W Additional Comments: ❑ Stk 466-6781 - ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385' a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201-eFEE _ )NFO AMOUNT DUE # 'AMOUNT REMITTED , CASH RECEIVED BY DATE P.E1�R'rr7 o. *,EH 13.241REv-1/851 - r —174 -- EH t4-285 -