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A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA "' Telephone (209) 466-6781 �c_ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '� � �\C1 (Complete in Triplicate) ,p [o Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descR `, is application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reg 10 of the San Joaquin Local Health District. Job Address 0 9A 3-- vc7/sc-4 5—& IVJ City Lot tze PM I Owner's Name - Address 1ffXy__M& A4dw go- Contractor Address �j�nse No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1�& DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _DISTANCE,TO NEARES.T,: SEPTIC.TANK/�____ SEWER LINES 'DISPOSAL FLD/_�PROP. LINE D i FOUNDATION AGRICULTURE WELL OTHER WELL�Q�I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -e ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Private Gravel Pack ❑ Tracy Type of Casing_, - S — Specifications-Domestic/ t I Public' ❑ Oth� - Delta Depth of Grout Seal Type of Grout I I Irrigation pprox. Depth t I Eastern Surface Seal Installed by r - Repair`Work Done ❑ Type of Pump H.P. ,� ` State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth .Filler,Ma erial (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is f 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 ❑ Type/Mfg Capacity No. Compartments 1J�1 PKG. TREATMENT PLT. ❑ 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 11 Depth Size Number l > SUMPS Ll Distance to nearest: Well Foundation Property-L'ine DISPOSAL PONDS ❑ 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 DiMrict. 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 applica us al or all r )red inspections. Complete drawing on rev a side. ^--�- Signed X Title: Date: 711 F DEPAR ENT USE O LY DateApplication Accepted by �/ Area Pit or rout spection by Data yFnal Inspection by Date r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Martia 104 ❑ Tracy 635-6365 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 CK ill RECEIVED BY ` DATE PERMIT'NO. INFO CASH +.EH 13-24(REV EH 14-26 9 -