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• APPLICATION .FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA j Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete a r Triplicate) � �H Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tl�� C s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R I bf the San Joaquin Local Health District. Job Address /�/S� +W1 e, I V .I N) ( I 1QQad City CJS ' — Lot Size pPM _^1 Owner's Name I L t/:)S oQ A�dddrreess{(7 I�� /�� 1/1QP'honeC O or Contractor I Address_Q3q 9 7�( rnQ License No.X119 —Phone TYPE OF WELL/PUMP: INJEAN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ q PUMP INSTALLATION 11 SYSTEM REPAIR 11 OTHER J (d oeofechnl axI501 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LYONE _ �r1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS dustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E) In ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout t vt I I Irrigation —Approx. Depth I I Eastern Surface Seal installed by - �T Repair Work Done ❑ Type of Pump H.P. LLMate W'onrk Ql.J Well Destruction ❑ Well Diameter _� Sealing Material ltop 50'1 !)e rtlii � loRe T P' -P VI 11 Depthri —�� Filler Material (Below 501 C TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is G available within 200 feet.) rn Installation will serve: Residence_ Commercial_ Other `r yV Number of living units: _ Number of bedrooms VI' Character of soil to a depth of 3 feet: Water table depth f� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line (l LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line (T SEEPAGE PITS I I Depth Size _ Number }� SUMPS ❑ Distance to nearest: Well Foundation Property Line VV 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 Di3trict. 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: "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 applicanp u cal fo all q it d inspections. Complete drawing anreverseside. (', Signed X 'I Y61 Title: t'rn i P !�P 1 SI Date: L1/ 1 /'T 3 FO DE RTMENT USE ONLY Application Accepted by Date 3 ea % f Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO �r y FH 13-24IREV.118 5) \ /'] v O9 // 0 EH N-26 . o