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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. r �j /��ii••��yy i Job Address �� AAl� ,S, O ��`�1� City �fd�CtAL Lot Size PM I 614L—823_J 10z Owner's Name L-(j Address 2 e Contractor 1 dress icense No.�—Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:-SEPTIC TANK 601SI-7 SEWER LINES DISPOSAL. FLD. PROP, LINE% FOUNDATION AGRICULTURE WELC- OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Y ❑ Manteca Dia. of Well Excavation 12/IVW. Dia. of Well Casing L? 1AW .Domestic/Private Gravel Pack ❑ Tracy Type of Casing S Specifications FI Public f_7 Other Cl Delta Depth of Grout Seal .(W�T�_._,--- Type of Grout I I Irrigation _V4Approx. Depth *,b4-Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ J. Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Fillet Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION,I.F REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if'public sewer is W available within 200 feet.) n Installation will serve: Residence_ Commercial— Other 'V Number of living units: Number of bedrooms i 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 C r SEEPAGE PITS - 1. 1 Depth Size Number SUMPS- - Ll -Distance-to nearest: Well Foundation Property Line - DISPOSAL PONDS ❑ w- J 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 D1"ltrict. Home owner or licensed agent's signature certifies the following: "I certify that.n.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 rtify 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 app IV all r all re red inspections. Complete drawing on r rse stdSigned Title: / Date: FOR DEPARTMENT U5 ONLY " Application Accepted by Date 7— Area c'- IO l� Pit or Grout Inspection by f r Date 1D y �v Final Inspection by '�� Y Date Additional Comments: D'�` /r .!/ - � Awl -- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manta 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 CASH RECEIVED BY DATE PERMIT'NO. / INFO +.EH 1 3-24 IREV.t i n 51 EH 14-26 � � O 09 �f