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F' .. APPLICATION FOR PERMIT D x� r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON CA Telephone (209) 466-6781 MAR 9 1N 7 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED-,Ik ` NVIROMENTAL HEALTW (Complete in Triplicate) t i PER MIT/SERVICES } - Application is hereby made to the San Joaquin Local Health District for a4permit to construct and/or install the work herein described.:This application is made in compliance with San Joaquin County pp q ty Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. � 0�� w -.� . - ,.. + Job Address y , �L Ci Lot Size' PM Owner's Name Addressf> F7* /� . _. Phone Contractor be / t Address c¢n o-&;,326 Phone " TYPE OF WELL/PUMP: NEW WELL El 17 REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ iA SYSTEM REPAIR ❑ OTHER El' -�» DISTANCE-70-NEAREST:-SEPTIC TANK— _ SEWER LINES D15pO5AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Rs ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .,@'Domestic/Private ❑ Gravel Pack: ❑ Tracy Type of Casing - Specifications ❑ Public ❑ Other d ❑ Delta Depth of Grout Seal f ` Type of Grout ❑ Irrigation ---Approx. Depth g Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. L State Work DoneT Well Destruction ❑ Well Diameter 's Sealing Material (top 50'1 Depth Filler Material (Below 50' TYPE OF SEPTIC WORK: NEW INSTALLA/TION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑^{No septic system'permitted if pu is se r ' s lfes av�ilablthin 200 Installation will serve: Residence-.-Commercial_ Other a°••• ✓✓�� i Number of living units: Numbe of bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPT C TANK a--•--C7-.Type/Mf J .-.--.->.-. - IQ g' � � Gapacity — `—No.-Compartments PKG. TREATMENT PLT. ❑ _� Y 3s d i Method of Disposal Distance to nearest: Well Foundation �2 3 - Property Line LEACHING LINE ❑ No. & Length of lines ` ' Y Total length/size FILTER BED ❑ Distance toy nearest : WellFoundation + .r r Property Line SEEPAGE PITS ❑ Depth Size Number ' SUMPS Distance-totnearest:, Well Foundation Property Line --- DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county oFdinances, 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." .' The applicant st ca for AIrequired inspections. Complete drawing on re a side. Signed clkl� Title: ! Date: FOR DEPARTMENT USE ONLY Application Accepted bAy ----I— L 6 ^� r Date —7/ Area G o Pit or Grout Inspection Date Final Inspection by'--M• Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 r ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 FEF AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE LRZ ERMIT N0. +EH 13-24(REV.I/as) - �//'-- EH 14-26 5. n b0�.-.4 _ .. i�l� �