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k APPLICATION. FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 l I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 Regulations of the San Joaquin ; Local Health District. 7 �( /. Lot Size PM Job Address I City "! Owner's Name r Address S ✓�" Phone Contract '� - ,4ddress Q ,License No. ,3ZVZZ ( Phone - /O'y _ i• TYPE OF WELL''/PUMP: NEW WELL" 11 � � WELL REPLACEMENT C] DESTRUCTION Elb 31r PUMP INSTALLATION 1-1SYSTEMREPAIR IDOTHER El' DISTANCE TO NEAR :-SEPTIC'TANK`: SEWER LINES DISPOSAL FLD. PROP. LINE + ' FOUNDATION AGRI L OTHER WELL PITS/SUMPS l INTNDED,USE ; TYP..E�OF WELL PROBLEM AREA CONSTRUCTIONS TIONS , " �O'_Industrial r� --i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑-Gravel"Pack r �f]``Tracy e. . Type of Casing Spe tions a ublic 't \171 Other S❑ Delta I Depth of Grout Seal 4 Type of Grout ❑ Irrigation aIrpprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ElType\of Pump ' H.P. State Work Done— + Well Destruction — ❑--Well Diameter i Sealing Material-ftop-50'i - Depth \ Filler Material (Below 501 TYPE OF SEPTIC WORK:--NEW-INSTALLATION -"AEPAIWADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is vailable within 200 feet.i' iInstallation will serve: Residence Commercial� Other A�S ,wbv�P Number of living units: Number of edrooms r Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK E1-`Type/Mfg �ttl Capacity No. Compartments PKG. TREATMENT PLT. ❑ e9I Method of Disposal Distance to nearest: Well 400 Foundation� Property Line .� 1 LEACHING LINE A-/No. & Length of lines r Total length/size X� I FILTER BED ❑ Distance to nearest: tiwell IQe_ Foundation _..— Property Line . ._ SEEPAGE PITS ❑ Depth Size4 r Number SUMPS ❑ Distance to nearest: Well- " �''-1Foundation Property Line DISPOSAL PONDS ❑ J ` 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 persons subject to-workman's compensa- tion laws of California." C', The applicant t call for all r uired inspections. Complete drawing on revers Signed X Title: i FOR DEPARTMENT USE ONLY Application Accepted by DateAWP rea 7 Pit or Grout Inspection by Date Final Inspection by Date / Additional Comments: 19 [DStk 486-6781 ❑ Lodi 369-3621 El Me 823-7104 ❑ Tracy 835-6385 —Applicant- -Return all copies to: Environmental"Health-Permit/'Services 1601-E.--Hazelton Ave;-P.O.--Box-2009;`Stk:"CA 95201r FEE AMOUNT DUE AMOUNT'REMITTED "'`CK ' ` RECEIVED By DATE PERMITNO. 41- INFO CASH + EH 1324(A EV.,i H 5)w ' •4-V �i-a"� EH 14-28