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p r5 a V 1 APPLICATION FOR-?'eVRMIT SAN JOAQUIN LOCAL HEALTH DISTRICT p' 1601 E. HAZEL ION AVE., STOCKTON, CA�v 'Telephone (209) 466-6781 E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' .(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.549Jor sewage or No. 1862 for we Local Health District. and the Rules and Regulations of the San Joaquin 4 '- " Job Address /1021r— �• /�J- --- City '1�71Ct Size_. PM ' Owner's Name .I Address Sa .M a Phone -- v Contractor, ' Address ' : Ow .32 License No ,�QoZPhone TYPE OF WELL/PUMP: NEW WELL ILI, WELL REPLACEMENT LJDESTRUCTIQN ❑ ' PUMP INSTALLATION O SYSTEM REPAIR OTHM ❑ ' DISTANCE TO NEAREST: SEPTd TANK SEWER LINES DISPOSAL FLO. I PROP. LINE FOUNDATION At AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial E) Open Bottom_ C Manteca Dia. of Wall Excavation Dia. of Well Casing G '�jDomestic/Pnva[e ❑ Gravel Pack ❑ Tracy Type of Casing �SpeciOcatlons �j C1 Public ❑ Otter EJ Delta Depth of Grout Seal 73 of Grout _ ❑ Irrigation �pprox. Depth Eastern Surfa Seal Installed by Repair Work Done K, Type of Pump 5� H.P. �= State Work Do C _ Q ' Well Destruction p Well Diameter � Sealing Material (top 50'1 — i 1 DBPthj, - - ^'-Filler Material (Below 50 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is y 1k available within i feet.) Installation will serve: Residence Covmerc181—'�4 Other Number of living units:_ Number of bedrooms I ii Character of soil to a depth of 3 feet: "% \. � 1 ,� Water table depth 4 SEPTIC TANK ❑ Ty 'Mfg ~'' Capacity No. Compartments x PKG.,TREATMENT PLT.❑ Method of 1Disposal Di ice to nearest:, Well I ; Foundation Property Line / LEACHING LINE ❑ No & Length of lines + Total len gth/si I ' FILTER BED ❑ Distance t Wit: l Well Foundetion Pro i rty Line � CSS ' SEEPAGE PITS ❑ Number_ ) SUMPS ❑ Distance,to nearest: Wall aFoundatio6t ` �r i Property Line I DISPOSAL PONDS ❑ I hereby certify that I he !t�' ' have prepard this application and that the work will;be done in accordance with dan Jo aquinlwumy ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 11 Home owner or licensed agent's signature certifies th0ollouring: "I certify that in the performance of thef work for ti, Wthis permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California/',Contractor'slifting or sub-contracting signature certifies,the following:"I certify that in the performance of the vhork for which)his.petmitis.issued,J.shalr-einploy perso subject to workman's compensa- tion laws of California." t The ap ieartt—lust call for all r wired i actio Complete ing ata drawn reverse sits:`-'C•-{ 1 Signed ,�� Title: \/, I ate: i{ FOR DEPARTMENT USE ONLY I �� Ar /0�� //}} Application Accepted 1 Data IS r 7 Area 1 Pit or Grout Inspecti n by �I Date Final Inspection by ' , Date /-/ Additional Comments: I - - - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk.,CA 95MI FEE AMOUNT DUE, - AMOUNT REMITTED - RECEIVED BY INFO CASH DATEJ nPERMITH 13-24(REV.I Is e! +U(� """ 1�