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i k s u APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED em (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinanc_e.No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the Joaquin Local Health District. ; J - 1 �}.,/ � ,,, „ I,�,��•„� _S� � Job Address _a City Lot Size PM Owner's Name Address aglaD/-Iy2�4) 1l IJ�/'h hone ]�99- 7J� Contractor Address f ikse No. %D��Phone 'fl' J� o TYPE OF WELL/PUMP: V NEW.WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK' //D � SEWER LINES' DISPOSAL FLD._!/O ' PROP. LINE I —FOUNDATION.- AGRICULTURE((TELL--=--O.EER-WELL-=2: --PITSiSUMFS"'�-- ---',:'� INTENDED USE . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private. Gravel Pack ❑ Tracy Type T 4 of Casing Specifications , ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ ��]D Type of out ❑ Irrigation -L—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 13 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 TAMC ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED El Distance to nearest: Well Foundation Property Line 0 SEEPAGE PITS ❑ Depth -Size Number SUMPS El Distance to nearest: Well Foundation PropertyLine _ - - DISPOSxCL'POIVDS ❑ - .— Pr -t rr c 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin &6& ordinances,'state•laws, and rules and regulations of the San Joaquin Local Health District. p - rr1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whidh""this peimit is issued 1 shall not employ any person in such manner as,to become subject to workman's compensation laws of California."Contractor's hlri' or su Lcontr ding signature certifies the following: certify that in the performance of the work for which this permit is issued,I shall employ person;�uI or tp workrrJi6 s compete- tion laws of California." t The applicant ust call forIre red inspections. Complete drawing on revers aide. T 4 Signed Title: yax: �1 FOR OEPA TM ENT USE ON _� � w �,,;;�•�+�� w� Application Accepted by Date V// qma Pit or Grout Inspection by Date Final Inspection byK::::�: Date Additional Commentsf� It'lah`,n lGtif 5rz�� t-et1 ,.-,,k.r� ❑ Stk 466-6781 ❑ Lodi 369 3fi21 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Appl!cant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 i FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO a EH13-241REV.t/651 EH 1428 C7 ' s