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.. APPLICATION FOR PERMIT "wo SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t and/or all the work n described. This made ntlompliance with Sanis oJoaqu nthe SanCounty ordinaJoaquin lnce No.549 for sewage o Health District for a permit 1862 for cwell/pump end the Rules and(Regulations of he SanlJoaquin Local Health District. i 1 ) �O AW i City Lot Size PM Job Address /ray y� � /(/'.,� (7(� ///� _ Owner's Name • • n - Address/ 2 . �/�.�Vj Y s' V-5391, 7�y,Pcyh"one _" O Address ��/ /License No. -53 Phone (/5-022 Contractor � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ S STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE — FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CO TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca . f Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications o F'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by - r i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 501 p Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I available within em permitted if public sewer is aila e.. Installation will serve: Residence Commercial_ Other (f4 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 PKG. TREATMENT PLT. ❑ 1 Method of Dlsposa I Distance to nearest: Well A l)T Foun anon Property Line LEACHING LINE ❑ No. 8 Length of lines 'r'1 , — Total length/size FILTER BED ❑ Distance to nearest: Well /0 0 of Foundation Q I? f . _ Property Line x.. SEEPAGE PITS 11 Depth Size � �Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 taws, and rules and regulations of the San Joaquin Local Health D13trict. 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, 1 shall not employ any parson 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 applicant ust call for all a0 ui dins coons. Complete drawing on reverse side. Signed X- Title: _� -rr7-Llit Data: LI7 FOR DEPARTMENT USE ONLY / 2 Application Accepted by Date`rte!!�� ' Area—�---- or Grout Inspection by D Date_�J_J�"4�L Final Inspection by./ Date�$ Additional Comments: +_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 -t� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 e�$-',c\� FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �J �.ER ta3N tREy.,rx51 INFO 1-7Q X33 Elitt-]a