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1 i I " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '4 YEAR FROM DATE ISSUED (Complete in Triplicate) r' 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 cmpliance 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. i il Joh Address F 'yam' City Lot Size - PM Owner's Name _ JA,(.,r Address F'V 3 Phone Contractor OW Q00sv' Address 3+ � F t License No. S51071 Phone TYPE OF iWELL/PUMP: NEW WELL1% LL REPLACEMENT ❑ DESTRUCTION E) 3 , ii� PUMP INSTALLATION ❑ SYSTEM ❑ OTHER *1114- DISTANCE TO NEAREST: SEPTIC TANK �v SEWER LINES DISPOSAL FLO.rIC / PROP. LINE j fl FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2— ❑ Domestic/Private A Gravel Pack ❑ Tracy Type of Casing ��c A-e� it--0 Specifications I'] Public{I� ❑ Other F Delta Depth of Grout Seal I g64 Type of Grout I I Irrigation �_Approx. Depth l I Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done i44 Well Destruction ❑ Well Diameter �^^�'�ealing Material (top 56') Depth ?�._... .".__� Filler Material (Below 50') TYPE OF i,SEPTIC WORK; NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it public sewer is 'I available within 200 feet.) s Installation will serve: Residence— Commercial Other Number[Of living units: Number of bedrooms + 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 'I a I LEACHING LINE ❑ No. & Length of lines Total length/size11. FILTER BLED ❑ Distance to nearest: Well Foundation Property Line SEEPAG#TPITS I I Depth Size Number SUMPS 'll ❑ Distance to nearest: Well Foundation Property Line DISPOSAL 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 IIregulations 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 for all required inspections. Complete drawing on reverse side. Signed XII Title: A Data: �I' le FOR DEPARTMENT USE ONLY Application Accepted by Date g Area Pitrout Inspection by Date 'z _tr Final Inspection by C�. �C ri %-I_ Date — Additional Comments: CZ 46V ❑ Stk466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant- Return arra// cop n7nm!nta Health�Permit/Servic 1_601 Hazelton Avg, ox 2909, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 1 +.EH 124 IREV. 4. EH 14�2e it