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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466_fi78, PERMIT EXPIRES I YEAR FROM DATE,ISSUED _. �_ (Complete in Triplicate) 1 44 Appecation rs,h reby made td the San Joaquin Local ea h Distrie�fp apermit to construct and/or install the work herein described.-3519 3 519-0 made in co with San Joaquin County Ordinance No.549 for sewa Local H 'ak�i District. or weft/pump and the Rules and Regulations of the SanlrJoaquin -.:.�.. -- m� n P� Job Ad O So 0 Owner's Name/--%2 hTCity 7 Lot ize PM /�,il- _ i Address Contractor's Name zle2 P . Phone J'2L y .�.,�4"x,,5 TYPE OF WELLlPUMP; License No. NEW WELL ❑ WELL REPLACEMENT ❑ Phon , E — �1 •� PUMP INSTALLATION [2DESTRUCTION DISTANCE TO NEAREST; SEPTIC TANK SYSTEM REPAIR 11 OTHER ❑ SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL PROP. LINE -INTENDED USE OTHER WELL PITS/SUMPS 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom ~�` -❑ Domestic/Private � Manteca Dia. of Wel! Excavation " ❑ Gravel Pack ❑ TracyT Dia. of Well Casing I❑ 1 Public C] Other Type of Casing ❑ Delta Depth of Grout Seal Specifications ❑ Irrigation —Approx. Depth ❑ EasternType of Grout ` ; E2Surface Seal Installed by Repair Work Done Type of Pump H P rWe11-Destruction PWell Diameter F� State Work one Sealing Materia! (top 50') Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑Filler Material lo DSTRUCTION -No septic system k Installation will serve: Residence A p miffed if public sewer is Commercial_ available within 200 feet.) 1 i Number of living units: Other_ Number of bedrooms �i Character of soil to a depth of 3 feet: Yl t SEPTIC TANK ❑ Type/Mfg Water table depth ; ty ! PKG. TREATMENT PLT. LlCapaci �� No. Compartments ' Distance to nearest: Well Method of Disposal I I Foundation Property Line_ 1 <LEACHING LINE ❑ No. & Length of lines _ jFILTER BED Total length/size ` _ ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth SUMPS Size Number ❑ Distance to nearest: Well DISPOSAL PONDS ❑ foundation Property Line 1. < 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. �- 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 tion laws of California." p p Y persons subject to workman's compensa- *The applicantt call for all required inspections. Complete drawing on re Signed " 1 Title. Date; FOR DEPARTMENT USE ONLY ti Application Accepted by I q,�� Date Area Pit or Grout Inspection by Date. Final Inspection by Additional Comments: Date-9-- C3 ate❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - -O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i fAMOUNT DUE AMOUNT REMITTED CK INFOFO CASH RECEIVED BY DATE i � PERMIT"NO. EH 13.24 fREv.f0183y �C EH 1428 -`�7to