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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL' HEALTH DISTRICT hit l 1601 E. HAZEL T ON AVE.,3 STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Qo (Complete in"Triplicate) ' F" .r t a : y'- 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 Localmade-n compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R41es and Regulations of the San Joaquin Local Health District. -'+��` � - Job Address City N Lot Size ' r' PM _ Owner's Name ��1 R^C T_ 6U A eCAddressK y N . . S-f / L - r Phone Contractor- C:Address ca6 License NoAao �! / Phone TYPE OF WELL/PUMP: ! NEW WELL LlWELL REPLACEMENT ❑ DESTRUCTION ❑ 1PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE'—TYPE. - ____ OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C1Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing T .Dia.of Well Casing ❑ Public ❑ Other ❑ Delta Specifications r�} Depth of Grout Seal Type'of Grout ❑ Irrigation -—Approx. Depth ❑ Eastern Surface Seal Installed by i41 Repair Work Done ❑ Type of Pump z H.P. State Work Done Well Destruction ! ❑ Well Diameter Sealing Material (top 501) Depth Filler Material fBelow 50') E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is Installation will sive: Residence A"''" - x vailable within 200 feet.) { J i i Commercial— Other t t Number of living units: Number,of bedrooms Character of soil to a depth - 3 feet: I SEPTIC TANK t XType/Mfg 11 t Water table depth PKG. TREATMENT PLT. Q jl " .,....a, Capacity t No. Compartments - I a' 1 Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE s ❑ lVo. &.Lengto of I"ihes d Total length/size FILTER BED ❑ Distance to nears•'Well Foundation Property Line } SEEPAGE PITS ❑ Depth Size E SUMPS Number❑ Distanc to Barest: ,Well Foundation DISPOSAL PONDS Ll Property Line 1 s 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 employ an � fY performance of the'work for which this permit is issued, I shall not P y 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 tion Iaws.of,California." P Y persons subject to workman's compensa- tion s The applicant t ca for all r ed in ons. C plete drawing on reverse sidd. } Signed -Title:: Date: f OR DEPARTMEN -USE 1 LY"— Application Accepted by bate p-� Area v Pit or Grout Inspection by Date 'Final Inspection by D �e� - Additional Comments: IV . - ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE II� AMOUNT REMITTED INFO t CASH RECEIVED BY DATE PERMIT"NO. + EH1 -24iREV.t/es) 1�r() p 2 + y EH 1426 : �7