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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � ' r s . 1 ; 00 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 t Nor PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� 'jr A (Complete in Triplicate) �N-V HCAL,IM Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wortko ibE_ " lcation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules an n o the San Joaquin Local Health District. Job Address ':7' 4%�� /�17�� 1 /�� City Lot Size PM Owner's Name ro IX4I10P7511 11-1 Address � Phone Contractor /,? y 29AKAddress`r2k�49 License No. _ks Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION .o?SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWI�R LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI ULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MantecaDia. of Well Excavation Dia. of Well Casing Domestic/Private C1Gravel Pack ❑ Tracy I Type of Casing Specifications f 1 Public ❑ Other [n Delta ( Depth of Grout Seal Type of Grout _-. I Irrigation _Approx. Depth 1 l 1 Eastern i Space Seal Installed by _ Repair Work Done ❑ Type of Pump { H.P. State Work Done Well Destruction ❑ Well Diameter ! Se$ling Material flop 50'i Depth ! Filler Material (Below 50'1 �_W TYPE OF SEPTIC WORK: NE. INSTALLATION I 1 REPAIR{ADDITION l I DESTRUCTION ( I (No septie system permitted if public sewer is available�vithirV�p feet.) Installation will serve: Residence Commercial— Other + Number of living units: I Number of bedrooms # �• Character of soil to a epth of 3 feet: Water table depth J SEPTIC TANK E� Type/Mfg Capacity No. Compartments s. 1 PKG. TREATMENT PLT. ❑ 4 Method;of Disposal w I �N Distance to nearest: Well Foundation Property Lin B , LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property.Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: �JWell ---Foundation– --Y "Pro-pe7ty�tine DISPOSAL PONDS ❑ r� I hereby certify that I have prepared this application and.-that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local health Di$trict.! 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 �I require �s. Complete drawing on revers side. 1 Signed X tie: _ Date: -e"A i 3 j DEPA NIENT USE ONLY Application Accepted by f Date Area Q Pit or Grout Inspection by Data Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental 14ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE j INFO MOUNT DUE AMOUNT REMITTCK It BY ED CASH RECEIVED DATE PERMIT'NO. rEH13.24IREV.1/851 �/ f 9<{-�,34P EH 14-26 vv . f