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� x APPLICATIOWFOR PERMIT ' ' SAN,JOAQUINWLOCAL-HEALTH DISTRICT 1601 E. .HAZEL T ON•AVE., STOCKTON, CA I Telephone (209) 466-6781 j ..,. � r .,r.., ti� ,',` . ?'� ��•q i�:SrJ'i '.'� ,.._ ._: 3 fr.� `, f �t h PERMIT EXPIRES 'I_'YEAR FROM DATE.,iSSUED T!,.0(Complete,in Triplicate) ,�; ., .. , .. �; �;•,; F, ��. ,, . r 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 or.No. 1862-for.well/pump"and the Rules and Regulations of the San Joaquin Local Health District—).1c. _1. rt i Y7 fr t J City L Lot S .]cize-;k oL&V PM Job Address Owner's Name Address '"'^' Phone ��Y ' License No. Contractor's Name ~ TYPE OF'WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE_ FOUNDATION AGRICULTURE WELL r: OTHER WELL PITS/SUMPS . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' 1 ❑ Industrial ❑ Open Bottom ❑ Manteca 11->Dia. of Well Excavation - Dia.-of Well Casing. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy r Type of Casing d Specifications ; }El Public O Other ; '❑.Delta Depth of Grout Seal- = '` 1Type of Grout f❑ Irrigation _ ___+pprox. Depth" ❑ Eastern,3 Surface=Seal Installed- 'Repair Nlo�k'Done t_❑+"Type of Pump H.P., ^^^-^ -1State Wark Done 1.., Well Destruction ❑ Well Diameter, Sealing Material Rop %'.) Depth Filler Material (Below 150'11 TYPE OF SEPTIC WORK: NEW INSTALLATION; .` REPAIR/ADDITION`❑" DESTRUCTION ❑ (No septic system permitted if public sewer is 5.„ 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: ► "_ —�6 � Water table depth SEPTIC TANK Or Type/Mfg 1B JCKCapacity -.... No: Compartments PKG. TREATMENT PLT. 1-1 " Method of Disposal * Distance to nearest: Well ` Foundation—.Property Line LEACHING LINE lel No. & Length�of lines D6i Total length/size `FILTER'BED ❑ Distance to nearest: Well -Foundation Property Line - l 1. } I fill - - - rSEEPAGE PITS ❑ .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 District. Home owner or lice•nsed,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 applic must call f all requir pections. Complete drawing'on reverse side. i (Signed t Title: G'O I`atry.. Date: # OR DEPARTMENT USE ONLY I Application Accepted by Date ��'� Area i {Pit or Grout Inspection by Date Final Inspection by Date ' Is Additional Commedts: a y [3Stk 466-6781 x ❑ Lodi.- 369-3621 ❑Manteca 823-7104 ❑•Tracy '835-6385 p to: Envitor-mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f V Applicant- Return all copies t IFEE NFO.' --,AMOUNT DUE p AMOUNT REMITTED C LA RECEIVED BY DATE PERMIT'NO. +EH 13-24 TREY.10!831 - •� M---- yE ' ��r�,J ., � EH 14.28