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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209)-466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) , 22-�--(3�� 22 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 i 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. fes' Ss� S –, rte-} Job Address - 4 ��xf f City Lot Size ' PM Owner's Name / 1 Address z 67 3 /lA� Phone - , r / Contractor • Address /" /"` License No. u-a 1 3 Phone 6- TYPE OF WELLIPUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 360 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r f ❑ Industrial ❑ Open Bottom 1 Manteca Dia. of Welt Excavation z Dia. of Well Casing ❑ Domestic/Private X Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other f ❑ Delta Depth of Grout Seal 751 Type of Grout -o Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done N Well Destruction ❑ Well.Diameter. Sealing Material (top 501 �} Depth I Filler Material (Below 501 V1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V1 available within 200 feet.) Ln Installation will serve: Res{deuce— Commercial Other Number of living units: Number of bedrooms 4� Character of soil to a depth of 3 feet:c Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. ❑-•-– • - } Method of Disposal i Distance to nearest. Well Foundation Property Line F LEACHING LINE: ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE,PITS ❑ Depth, j F Size Number SUMPS ❑ 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 regulations of the San Joaqui6 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 Calif rnia." The applicant m st call for all require spections. Complete drawing on re erre sid . Signed Title: Date: FOR DEPART ENT USE ONLY L-26'Application Accepted by v " Date (r Area �7 Pit or Grout Inspection b ' Date ! ' Fina( Inspection by� ^ – Date Additional Coments. cv a-s b-1rIV d- -7-Z,3–§6 VV' S s ❑ Stk 4W6781 h Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 (f 4 'i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13.241REV.1/$51 � � ��p^ 9n ' EH 1425 h