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r ,1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL�.HEALTH DISTRICT 1601 E. HAZE T ON 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 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 orNo. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ii ry } i Job Address Z 6 Z 00 A& City o/O?�y? Lot Size PM ! I Owner's Name/r;-y4'&' Address Pr�r 17�.Y Phone 4—F'y71`SS/y i /�� a 4,57�d Contractor 1..5&, � rhQ� Address 13��E+'�r►1�! 9uJr�.J';r License No. Sf 3�� 7' Phone 416-66,?--5-3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X S-1d ,tri DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES I' DISPOSAL FLD. �-�� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLT,Zf'._.. PITS/SUMPS -7-- INTENDED —INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of?Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public ❑ Other ❑ Delta Depth of Grout Seal Type of.Grout L'1 I I Irrigation �S .Approx. Depth I I Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 lu o - Depth Filler Material (Below 50') %; N TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is if available within 200 feet.) O I1 Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms ° j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ; PKG. TREATMENT PLT. LD Method of Disposal Distance to nearest: Well Foundation Property Line II LEACHING LINE ❑ No. & Length of lines ' Total length/size r' FILTER BED ❑ Distance to nearest: Well Foundation Property Line 13 l SEEPAGE PITS I I 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 laws, and rules and regulations of the San Joaquin Local Health Di§trict. R Home owner or licensed agent's signature certifies the following: "1 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- tion laws of California." C f/ The applicant must call for all required inspections. Complete drawing on rev&se side. Signed X Title: P�C3L, S> /"��1��/� Date:I_� 60, I R FOR DEPARTMENT USE ONLY ' '} Application Accepted by hate # � ..` Area Pit or Grout Inspection by a �Tinal Inspection by ® Additional Comments: Ct(_) 1: 2 D Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7174 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE It INFO AMOUNT DUE AMOUNT REMITTED CASH EH RECEIVED BY DATE PERMIT NO. . 1 CpOD Z . CID ZZ i ♦.EH 13-241REY.+�nsy C.�'5� EH 11-28 I�