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APPLICATION FOR PERMIT ` a j SAN JOAQUIN LOCAL HEALTH DISTRICT k t 1601E>.HAZE' TON AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (Complete in Triplicate) F 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 Local Health District. E Q ee�. . Job Address City ��t"i�Size PM qTA 06 Own Name Oddress � —I Tl d�,WILI�i R?rIPP slfoc 3d Oa- Contracto �- sk Address. i _t ` License No. 1-h 2- Phone O b—9 D TYPE OF WELL/PUMP: •, N W WELL F1- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ` ' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTfC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FQUNDATIONr AGRICULTURE WELL OTHER WELL PITS/SUMPS NTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑;.Open Bottom ❑'Manteca pia. of Well Excavation Dia. of Well Casing womestic/Private L ❑ Gravel-Pack ,- %b'Tracy Type of Casing Specifications 11 Public �� C1 Other �yn,-Delta-„,..Depth,of_Grout_Seal_ Type of Grout _ \1 ! I Irrigation j r _.Approx.l De Ih R I'1 fa ern---_ .,,5 ace Seal InStalled'by.-` ' --' t Repair Work Done ! f�Type of Pump c State Work'Done_ TM t s , , Well Destruction r ❑ Well Diameter rI Sealing Material (top 50') W Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I RFP_.AIR'/ADDITION i I DESTRUCTION [ I (No septic system permitted if public sewer is n available within 200 feet.) 1 Installation will serve: Residence yCorrmmeicial _ Others-^--- Number of.living units: 1 Numberr of bedrooms Character;of soil to a depih_of'3 feet:!” Water table depth SEPTIC,-T K ❑ 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 SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 171DISPOSAL 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 rules and regulati t e n Joaquinl Local Health Diltrict. - Home owner ice agent' signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not employ an person rr such ma nja ome suN t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies a following: "I Ce y trforma e f the work for which this permit is issued, I shall employ persons subject to workman's compensa tion la sofi rnia."The ppficaI all ret e drawing on side. Signe Title: '� Date: _74 ENT USE ONLY f Application Accepted by Dat Area 1 i i Pit or Grout Inspection by Date Final Inspection by Date ( Additional Comments.- El omments:❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environ rn ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INF MOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED BY DATE PERMIT'NO. '+ EH14-2BEH 13-24 IREV.tiiH5f rVv I C_"1r t j