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„. APPLICATION FOR PERMIT 2 0 [t Q r 3 a SAN JOAQUIN LOCAL HEALTH DISTRICT ”' 6 1601 E. HAZELTON AVE., STOCKTON, CA [ �©3 Telephone (209) 466-6781 tJ" 'PERMIT EXPIRES 1 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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address rX / . �f} h-$- k _ _ City Lot Size PM Owner's Name ,�i�H�>✓ AlF1/l/4.dress 5� �-- Phone Contractors L 775 AwlZA- Address 9 SX1e13 s��/Il _ License No Phone�!►� CO TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ,V ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private f ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public s ❑ Other T 0 Delta Depth of Grout Seal Type of Grout I I Irrigation - _k.Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump I H.P. State Work Done _ T WeII-Destruction LJ;Well Diameter' r"` Sealing Material Itop,501 ;5 .. .f, t��-`� Depth Filler Material (Below 50') TYPE OF.SEPTIC WORK: NEW INSTALLATION l 1 REPAIR ADDITIONK DESTRUCTION { I (No septic system permitted if public sewer is ,, 1: { available within 200 feet.) Installation will serve: Residence_ Commercial_ Other F Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: !Water table depthIt �l SEPTIC TANK 171Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ f. Method of Disposal Distance tc nearest: r Well Foundation Properly Line LEACHING LINE ` CI No. & Length hof lines" Total length/size FILTER BED I . 0 'Distance to nearest: Well Foundation Property Line I i SEEPAGE PITS 'I 1 Depth _Size Za Nu ber SUMPS $ Distance to nearest: Well t9 r Foundation Property Line—=S DISPOSAL PONDS t ❑ s 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 District. `y 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 Caiifgr } e T;he'applicant us all fdr required inT cti ris. drawing on reverse side. Signed X Title: bate: r 4 � FOR DEPARTMENT USE 6NLY it j Application Accepted by iJ 't�` ""' _ - _ " f Date Area s f Pit or Grout Inspection by � � Date Final Inspection by ! Dat , Additional Comments: A0101', ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 1123-711021 ❑ Tracy 835-6385 ,cry d�,`K0 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 ! INFO AMOUNTCK NO. NTT DUE AMOUNT REMITTED ASH RECEIVED EIY DATE PERM t.EH 13-24{REV.t/it 51 EH 14.2e