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APPLICATION- � L,OCA."FOR PERMIT SAN JOAQUIN' L HEALTH DISTRICT �1 1 1601 E. HAZE T ON AVE., STOCKTON CA OCTr 198 Telephone (209) 466-6781 PERMIT EXPIRES 1i YEAR FROM. DATE ISSUED SAN'JOR" t1ilV ""P�rF�l1; TH �RS�I7l {.Complete in Triplicate} 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.,.tlSfi,{ Job Address d LIr,. Q n f` r ,. r •`i):.-: , City a`„ Lot Size z PM Owner's NameAddress -'_ — - Phone L'� - j`7 Contractor's Name �-� ^ �� License No. C/rnJ , Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Er-- OTHER 9 -- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION -AGRICULTURE WELL OTHER WELL'— PITS/SUMPS — - INTENDEp USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial-❑ Open Bottom❑Manteca Dia. of Well 1 Excavation _ Dia. of Well Casing 22"Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout " ❑ Irrigation --Approx. De th ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. IState Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 501) Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW iNSTALLATION ❑ "REPAIR/ADDITION ❑ DESI Installation will serve: Residence _ Commercial _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Other 4 ,'t Distance to nearest: Well R LEACHING LINE FILTER BED SEEPAGE PITS 'SUMPS -11 DISPOSAL PONDS ❑ No. & Length of lines ❑ Distance tonearest: s ❑ Depth 4 ❑ -Distance to nearest: (No septic system permitted if public sewer is available within 200 feet.) Water table depth _ Capacity _ No. Compartments } Method of Disposal cation Property Line - Total length/size Well' Foundatlon Property Line Size { y Number Well } * - - ; Foundation- Property Line 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: N— - 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- i -tion laws of California." The applicant ust color all required inspections. Complete drawing, on ree Sid . a Signed X��., �1iF•-,.-�- Title:G'-r'�^yc—.� Date i / S FOR DEPARTMENT.USE ONLY ',Application Accepted by w _ Date Area Pit or Grout Inspection by Date Final Inspection by � pie . Additional Comments: ❑ Stk -466=-6781- .r ❑ 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 !-INFO CASH FEE AMOUNT DUE 7 AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. + EH 13-24 iaEv. to/e3) ,EH 141B v 4<1