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�J+ J7 05,11,6<1 QfOu� J APPLICATION FOR PERMIT i iS SAN JOAO.UIN LOCAL HEALTH DISTRICT L�j 1601 E. HAZEL T ON AVE., STOCKTON, CA 0 l",T -- E 19834 Telephone (209) 466-6781 ' F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AN .l7AQUiN LOCAL w (Complete in Triplicate) -1gi.Ts i niRl.{'T Application is hereby made to the: an 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 Nw;1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. � [t (,j�rar iC OC-, City7ot Size PM Job Address ^'i ! dp TOwner's Name I J� Address one Contractor's Name ;L�4_'Ad '611 License No. Phone 3 �� TYPE OF WELL/PUMP: iI NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPI INSTALLATION 1:1SYSTEM REPAIR 11- OTHER P DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - - PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing Domestic/Private ❑ Grabs/ Pack ❑ Tracy Type of,Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern f rface Sea! Installed by Repair Work Done 17 Type of Pump H.P. Sta Work o Wel! Destruction El Well Diameter Sealing Material Itop 50') Depth j y '` ,Filler Material (Beiow;50;) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION Ll (No septic system permitted if public sewer is , available within 200 feet.) Installation;will serve: Residence_ Commercial_ OtFie'r'� Number 6f-living units: Number of bedrooms N�i " i , • y Character of soil to a depth oV feet: ''' {` - Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ I� I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation `Property Line SEEPAGE PITS ❑ Depth Size I ,.p Number SUMPS 17D stance to nearest: Well Foundation Property Line DISPOSAL PONDS El II _ 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 Sari°Joaquin Local Health District. 1_" Home owner or licensed agent's�signature certifies the following: "I certify that iri 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." Contractors 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." Ili I, The applicant mu V ca for quired inspections. Complete drawing on reyerse side. iA— Signed i Title: Date: FOR DEPARTMENT USE ONLY �r Application Accepted by 6 Date f Z Area w, Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 623-7104 ❑ Tracy 835-6385. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO +EH13-241REV.10/831 EH 7428