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APPLICATION FOR PERMIT yo8'1 ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ,�10 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S E P 1 �7 (Complete in Triplicate) i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor&WMhRQMW; .l4gi W is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules anJPEftM0'ftA@ifM 6Joaquin Local Health District. Job Address [�U/ •�� , 1`�f City +L Lot Size PM Owner's Name,^ £r,S1' rL 'fukddress Za 90-1W Phone / ell �,�� p q [[ Contractor Address�-. >/ / �-X. License No./G_a.3 '73 Phone TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q' 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 2'Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F) Public n Other Cl Delta Depth of Grout Seal Type of Grout ! I Irrigation --Approx. Deptl 11�Ea�stern Surface Seal Installed by Repair Work Done 9/ Type of Pump /�' � H.P.� State'Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f -� Depth '" Filler Material (Below 50') is TYPE-OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION I l DESTRUCTION i I (No septic system permitted if public sewer is I , available within 200 feet, i Installation will serve: Residence - Commercial Other Number of living units: t. Number of bedrooms Character of soil to a depth of 3 feet: i' Water table depth SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments ;t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line EE4 LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line i s - SEEPAGE PITS I'] Depth ~• Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 4 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: 1 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 i 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." t I The applicant m s call r all requir inspections. Complete drawing on r arse side. # '7 Signed X ills: moo/ Date: FOR DEPARTMENT USE ONLY ]� Application Accepted by — Date Area '✓ Pit or Grout Inspection by Date Final Inspection by4— �. Date a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385' ' I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOU REMITTED CK RECEIVED BY PATE PERMIT'NO. INFO CASH + EH 13-24{REV,1/x 5] � ! EH 14-28 7 I