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'� • �-,ems.-,.-�--�-�+^�` 1 • � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone {209) 46e - '�(uS,T y a r I PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) k 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, 4 V ob Address �W 3 U J40 C/�� City 1 Lot Size A0 AC V- 5- PM Owner's Name r c. r� Address ' 1 ' 1�i' � �r;if FiL`�; 1-��i Ph... ��' a Contractor / Address License No>SxSv�,�l Phoneme /a� TYPE OF WELL/PUMP NEW WELL J� WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLO./ PROP. LINE FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r I O Industrial Open Bottom Manteca � Dig. Qf¢S��Excavation Dia. of Well Casing b Domestic/Private Gravel Pack ❑ Tracy ype o Ca'A2 ��`, S�Z )` Specifications M Public n Ottl)er f 1 Delta Depth of Grout Seal Type of Grout I I Irrigation f Approx.rDepth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 73 Well Destruction © Well Diameter Sealing Material {top 50'1 Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth I SEPTIC TANK ❑ Type/Mfg# 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS I I Depth I Size _ Number ]; SUMPS Ll Distance to nearest: Well Foundation Property.Line DISPOSAL PONDS ❑ 4 1 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 I Local Health District. ► Home owner or licensed agent's signature certifies the following: 1 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 Ca' rnia." The applicant m st call f all re irad ins cti raving on reverse side. Signed Xr Title: date: OR DEPARTMENT USE ONLY t Application Accepted by Date Z Area 21.9 9 Pito Grout Inspection by Date Final Inspection by Datp✓� P Additional Comments: �e- '� - g J ❑ Stk 466-6781 ❑ l i 369-9621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED`BYFDATE PERMIT'NO. r.EH 13-21fREv.t/n51 �30 EH 14-20 {