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APPLICATION.,FOR,PERMIT SAN JOAQUIk1OCAL-HEALTH DISTRICT ` 1601 E. 'HAZE i OWAVE., STOCKTON, CA Telephone {209} 466-6781 x_i-,nnl:# s��! r,.�irrrSt"f)vi ys) ;"}! #-`�!rFF�#1 �'Y•;'f''# '!'...w �'�'.7`:��i��7 �.�1rt��l�� .i ' PERMIT EXPIRES.:1 YEAR FROM.,DATE,ISSUED y 33 ♦ - - - - - Ld brZ lt-� lCornpkete,ira.TflpllGBt }FI!SC3v('4C31i: 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,compliancaiwith San,Joaquin,County Ordinance'No.,549 forisewage or No:41862 for welllpump and the Rules and Regulations of the,San-Joaquin Local Health District...;G `,r, r,j "01C)< n '= r� ;q 1: `*'" + r ?;? T °! k� €eet)CICIb e 6',a { arta,'. F � v, �. Job Address `f 730 ' Z� City Lot Size PM Y - ..�.__._. <:.�.-r .. _- _ ..'"' -- _;,-...;-.�., �....., •._.-,t _�.._._.�� /�� f� � Owner P Owner'- Name Address ��` hone Contractor's Name ; License No Phone \ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION j�r, �V PUMP INSTALLATION ❑` ` SYSTEM REPAIR'❑ OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK.. SEWER--LINES DISPOSAL FLD. PROP. LINE O FOUNDATION ; AGRICULTURE WELL` OTHER WELL PITS/SUMPS INTENDED-USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ° I ❑ Industrial ❑ Open'Bottom ❑ Manteca Dia.-of Well Excavation .Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type,of 'Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! Type of Grout ❑ Irrigation - ---Approx.,Depth ❑ Eastern Surface Seal Installed by ?. Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter j Sealing Material {top 501 ' Filler Material {Below 50'1 Depth-. .. .. _ - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ..REPAIR/ADDITION © -DESTRUCTION ❑ (No septic system permitted if public sewer is. - - available within 200 feet.] t Installation will serve: Residence Commercial Other # Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -----L:Water table depth SEPTIC TANK ❑ Typa/Mfg i Capacity-, "No. Compartments ' PKG. TREATMENT PLT. ❑ 4 Method of Disposal Distance to nearest: Well: Foundation t Property Line 'LEACHING LINE F-1 No. & Length of lines j ' .Total length/size- FILTER BED ❑ Distance to nearest:" -well ell Foundation ;'Property Line f SEEPAGE PITS '❑ Depth Size Nuinberr I F " Well' Foundation Propei rty Line❑ Distance to nearest: w r I DISPOSAL PONDS ❑ t _ . i ` ' I her certify that I have prepared this application avid that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health,iDistrict. :Home owner or licensed agent's signature cert-dies the following: "I certify that in the performance of the work for which this permit is issued, I shad not i employ any person in such manner as to become subject to workman's compensation laws of California."-Contractof 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." 3 Ill i s ct• Co late drawin on reverse side. The applicant u call for all pe f- P 9 F �wSigned Title: r Date: c T.w -d FOR DEPARTMENT USE ONLY -7 Application Accepted by Date Area . At or Grout Inspection by Date Final Inspection b Date I� / Additional Comments: , t ❑ Stk -466-6781 O Lodi'_.,369.3621 ❑ Manteca 823-7104 ❑ Tracy 8354=5 'Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,:Stk., CA 95204 1 _ � - } FEE'. `AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. INFO CASH _ �f EH 13-24[REV.101831 1 EH 4428 11