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l APPLICATION FOR PERMIT li SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON,�CA , Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED [old70-— Ik (Complete in Triplicate) I� 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. Job Address ! i jt J City rc� Lot Size kfc.6 PM - 2- E, ��2f�.a1c{-, Owner's NameTil:. sic kIN16m t_},Tt)04 Address Z ---P U.S ' DdYL.1.74-tt 1`- 212- Phone � li Contractor f' j"t t CX '�Ol Arh ,Address 1 ! f oar-frr License NoPhone '� TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [a l t !�, "jjj ivf# DISTANCE TO NEAREST: SEPTIC TANK i:W C ' SEWER LINES r'I aJ I� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELD Ujj it OTHER WELL>_� .f- PITS/SUMPS — u INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc1-}aavation 0j�G , Dia. of Well Casing Ilk El Domestic/Private El Gravel Pack Tracy Type of Casino Pklf, L 1W' Specifications f-I Public R 4 FLl'rt'( f-1 Delta Depth of Grout Sear 4 Type of Grout rV '?1 l I i Irrigation +,"' :)'Approx. Depth i I Eastern Surface Seal Installed by C ,, ty w1 s 7j,t II Repair Work Done ❑ Type of Pump H.P. State Work Done ,f Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC RK: NEW INSTALLATION I] REPAIRIADDITION I.1 DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet., Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ T I ype/Mig Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size + I FILTER BED ❑ Distance to nearest: Well Foundation Property Line - I SEEPAGE PITS ['I Depth Size _ Number h SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .i 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 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 Califo nia." The applicarl i call for all requi ed 11 c ions. Complete drawing on}reverse side. :r Signed X ( Title: F r FOR DEPARTMENT USE ONLY li Application Accepted by Date L�._.._ Area Ii' ' Pit Grout Aspection by Date�� Final Inspection by Date - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE ii INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. _ iI + EH 13-24(REV. /x 51 EH 14 26 w