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L-*44 .°v} APPLICATION FOR PERMIT SAN JOAQUINr LOCAL HEALTH DISTRICT 1601 E. HAZELTON''AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED } (Complete in Triplicate) Application is hereby made to the San Joaquin Local Heath Distfict 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 sewlage•or No. 1862 for well/Qpu�m_p and the Rules and Regulations of the San Joaquin Local Health District. N�o.r�� Lk v 11 Q ` ` ' �� 1 ZQ r O i Job Address City Lot Size PM ' I Owner's Name �l'J �qcAddress'_ � Phone Contractor. I� Address a�- 644 cense No._S 3�� Phone , TYPE OF WFLLYPUMP: I�' NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �`M1 -P(JMP INSTALLATION � SYSTEM REPAIR ❑ OTHER C3 b S DISTANCE TO NEAREST: SEPTIC TANK .1 Mlk SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIS. ❑ Indu I open Bottom ❑ Manteca Dia. of Well Excavation !h Dia. of Well Casing omestic/Private ❑ gravel Pack O Tracy Type of Casing- Specifications C Afi 17 Public ❑ Oper H Delta Depth of Grout Seal �Q Lt cdType of Grout I I Irrigation `361.Approx. Depth I I Eastern Surface Seal Installed by s.-� - Repair Work Done ❑ Type of Pump c H.P. State Work Done I4 Well Destruction O Well Diameter Sealing Material (top 50') 1 -De pth Filler Material (Below 501 OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will Residence— Commercial_ Other Number of living units: umber of bedrooms. t �� } Character of soil to a deptho i f 3 feet: Water table depth SEPTIC TANK O 1Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r !'Distance to nearest: Well dation Property Line i LEACHING LINE ❑ No- & Length of lines ngth/size FILTER BED ❑ .Distance to nearest: Well Foundation Prop ine 1 SEEPAGE PITS I,I Depth Size Number SUMPS L1 ~Distance to nearest: Well Foundation Property Line i s DISPOSAL PONDS 0 r 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, ant } 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: "1 certi 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." ZI ,t•� The applicant st c I r a,11,required in ctia Complete drawing on reverse side. Signed X Title: l / � �� Dater .2::l " 1 - _ FOR EPART ENT USE ONLY � •' !� - � � l Application Accepted by I Date ,Area Pit or Grout Inspection by I� sj• Date l � -I Final Inspection by Date OL z- y Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823;11W` O Tracy 835-6385. r Applicant - Return all copies to: Environmental HealtW Permit I Services 1601 E. Hazelton Ave., P.O. box 2009, Stk., CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. 1N INFO c •.EH 13-24(REV.rin 51 /l.iC,;Ov 7n