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_ ......r .r APPLICATION FOR PERMIT x/39 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.TON AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) tt .i_r,1 1{..• Ll i t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heleinlat to wd.Tbhi4 applirs'9n is made in compliance with San Joaquin County Ordinance No.599 for sewage or No. 1862 for well/pump and the Rules and Regulalanslof'the tan Joaquin Local Health District. Job Addressy A ' C Lot Size PPA Owner's Name Contract ss License No. Z. 7 3 Phone TYPE OF WELL/PUMP: NEW LL O WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR A" OTHER O 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 O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public - ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _' I Irrigation //__Approx. Depth�`I`I EELppstern SudaiLe Seal Installed by Repair Work Done I!f IyDe of Pump � H.P. 'J� State Work Done T Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is S� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other '($\ 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. Companments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota1'length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGEPITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s, 1 hereby certify that I have prepared thig application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San Joaquin Local Health District. Home owner or ' d agent's nature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any rson in su manner as to become subjec workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies t following: "I c if that in the o a o khe wo ich this permit is issued,I shall employ persons subject to workman's compensa- tion la of California." . The licant -st call f all r ed . Comp to drawing jt&a� Signe X Title: Date: FOH ARTMENT USE ONLY f/ oN Application Accepted by ' - Date L`l' —l� Area Pit or Grout Inspection by Date Final Inspection by ��t. Date/,V "/7 -ffse Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMO�DUEAM NT REMITTED CASH RECEIVED BV DATE PERMI7 NO. INFO //�� // J fry/� // r, •.EH 1124 IREV.r,nsr . .�� H./ 'l./ //%3��I1 / �C//�L