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a — rAY APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781' ` - PERMIT EXPIRES 7 YEAR FROM DATE ISSUED I < (Complete.in Triplicate) t, 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 well/pump and the Rules and Regulationsaquin Local Health District. Ji; i of the.San Joaquin y Job Address dl � City Lot Size PM 5 / z Owner's Name + Address �i�l ✓n " hone License No. PhoneContractor's:Name - TYPE OF WELL/PUMP: i�l NEW WELL ❑ —WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION 4 SYSTEM REPAIR OTHER ❑ DISTANCE T0.NEAREST: SEPTIC TANK _L SEINER.LINES I�)p DISPOSAL FLO. PROP. LINE .q. FOUNDATION 1�-AGRICULTLF1RE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM' AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial!. ❑ Opert Bottom ❑ Manteca ; .Dia. of Well Excavation Dia. of Well Casing i _ Domestic/Private ❑ Gravel Pack ElTracy --Type.of Casing Specifications ❑ Public ❑ Other' ❑ Delta Depth of Grout Seal Type of Grout ❑ 'Irri ation 9 _Aplprox. Depth ❑ Eastern SInstalled by Repair Work;Done ❑ Type of`Pump H.P. u ace Seal State Work Done Well Destruction El Well Diameter n ' Sealing Material (top 50') Depth j. W/ Filler Material (Below 501 I TYPE OF.SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �- 4,` available within 200 feet.) ..- r4. may,1 Installation will serve: Residence_ Commercial Other L U Number of.living units: Number of bedrooms i Character of soil to a depth of 3lteet: ll Water table depth SEPTIC TANK ❑ Type' Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r -AJ.. _._ . Dista;n ce to nearest:- =Well — Foundation Property Line =-- - r. ._.�-.—�; LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distace to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Dep tFi Size Number SUMPS ❑ Distance to nearest: Well FoundationProperty Line DISPOSAL PONDS 1-1iiii 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 Joak.quin Local Health District. Home owner'6r 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 fallowing:"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." SIN, The applican ust c for all requiryrh IpTections. Complete drawing on re)rse side. Signed "I tCC"��jr I Date: {� d`.) D 7 FOR DEPAR ENT USE ONLY Application Accepted by '� p (� date `�v Area Pit or Grout Inspection by Date Final Inspection by Date J I Additional Comments: ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT D6 AMOUNT REMITTED CK "RECEIVED BY . DATE PERMITN0. CASH � +EH 13-24 IREV.101da8311 � � EH 1426 i S � � cso !