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APPLICATION FOR „ + � R PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I r i Telephone (209) 466-67$1 _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) - . .. I .: Application is hereby made to the San Joaquin local Health District for a permit to construct and/or in 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 Local Health District. a�fd'I E ' Job Address /U L�� - City_/ydJu/ Lot Size_ PM + _fOwner's Name Af Address Phone Contractor r z # Address /L *� TYPE OF WELL/PUMP: License No / Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i DISTANCE TO NEAREST: SEPTI PUMP INSTALLATION El SYSTEM.REPAIR E)C TANK OTHER El_ SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION � AGRICULTURE WELL _ OTHER WELL PITS/SUMPS �! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i, ❑ Industrial ❑ Open_Bottom r --- -- -•,— - - . �._..�❑ Manteca ..,_ Dia. of Well Excavation _ a ❑ Domestic/Private F] Gravel Pack ❑ Tr � W �.-.Dia•_of WeN_Casing_;, ❑ Other fl Public t acy T ype of Casing Specifications ❑ Delta Depth of Grout Seal P Irrigation ---Approx. Depth C] Eastern Type of Grout Surface Seal installed by ; Repair Work Done ❑ Type of Pump H p ; Well Destruction ❑ Well Diameter State Work Done_ Sealing Material {top 50'1 1 Oepth,r "I J�: r- i_ � k V Filler Material (Below 50') t c TYPE OF SEPTIC WORK: NEW INSTALLATION REP.AIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer;is Installation will serve: ResidenceZ"""� available within 200 feet.) i _L Commercial;. Other Number of living units: Number of bedrooms Character of soil to a depth.of 3 feet: s' Oi '' SEPTIC TANKType/Mfg Water table depth RKG. TREATMENT PLT!❑ , Capacity l/'la No. Compartments [ Method of Disposal i Distance to nearest: Well_,(fQ — Foundation '� r T Property Line G"r —_ { LEACHING LINE No. & Length of lines # FILTER BEDTotal length/size Distance to nearest: Well Foundationproperty Line SEEPAGE PITS ❑ ' Depth Size SUMPS Number a - t ❑. .Distance to nearest: Well Faundation'� DISPOSAL PONDS Property line ❑ V y., I hereby certify that I have prepared this.applicatio` nd_that the work will be done in accordance with San Joaquin coon ��= r rules and regulations of the San Joaquin Local Health District. r q county drdinan6es, state laws, and Home owner or licensed agent's signature certifies.the following: "f certify that in the performance of the work for which this permit is issued, I shall not r employ an r., P y Y person g such manner as 10•become subject to.workriian's collipensati n laws of California:"Cntractor's(tiring or sub contracting signature certifies the following: "I certify that in the performance of the woik - u ihic: this permit is issuers I shall em" ploy laws of.California." -- - p y persons subject to workman's compensa- The applicant must call four 1.requ' d inspections Complete drawing or reverse side.�� r ~ Signed X ef or r - "Title: �." 7" }7.;.r Date: t FOR DEPARTMENT U�SE ONLY i ;Application Accepted by Area r Date ? Pit,or Grout Inspection by Date ( / Final Inspection by Date G" ;Additional Comments: # F ❑ Stk 4615-6781 ❑ Lodi 369-3621 f ❑ Manteca 823-7104 13 Tracy 83x6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk CA 9520,1 ` FEE -►- AMOUNT-DUE,». - AMO)/fV Ixf1EM17TED . .r. + INFO` `, CK `RECEIVED BY- F . CASH DATE' _* PERMIT'No..".':.. *:..- _-• i + EH 9-24.fREV:-ii.H d`µE . EH 14-28