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�c APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r�� Job Address �I �� d,"61T.Jrt/ 1FFr _ City .3/70C0rTChJ Lot Size PM Owner's Name ` Address CL O�Dj 64 e dri 1 Phone If 5�-��IYM ��is(�'16Y1 aS�s E1��r1'le �7tiAG-KZ[4i_lA...►✓ l�rM4�1 R,��+FJ� �� ' "'� ��a� I - Contrac or TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �I� _ DISPOSAL FLD. PROP. LINE {z FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS h -i— ll Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation �' Dia. of Well Casing X Domestic/Private A Gravel Pack ❑ Tracy - Type of Casing PVC Scli SIO Specifications I'1 Public #4Ni>&1lr6.. ❑ Other Cl Delta Depth of Grout Seal 35� Type of Grout r I I Irrigation 4jF_zR �_Approx. Depth l l Eastern Surface Seal Installed by ]-R8nrrE'PiPg: _ Repair Work Done ❑ Type of Pump �51f� H.P- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filter Material (Below 50') E OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION I I INo septic system permitted if public sewer ' e available within 200 feet.' Installation w. e: Residence_ Commercial_ Other a Number of living units: Number of bedrooms ' Character of soil to a depth of 3'fee . ater table depth SEPTIC TANK Q Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 1-1Methodof Disposal Distance to nearest: Well ounda 1 Property Line I LEACHING LINE- ❑ No. & Length of Total Ieng e FILTER BED ❑ Distan nearest: Well Foundation Property LI SEEPAG�FITSt I Depth Size NumherSUMPS0 Distance to nearest: Well Foundation Property Line SAL PONDS ❑ i hereby certify that I have prepared this application and that the work will be donq.jn accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. —� 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject toworkman's compensa- tion laws of California." The applicant must call for all require spections. Complete drawing on reverse side. Sig a �q ak ser: 4. pt-1-126 its FOR DEPARTNfeNT USE ONLY Application Accepted b Date Area pp p Y Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED KASH RECEIVED BY DATE PERMIT NO, it + EH 13-24 iREV. / 51 �� EH 14-26 C_XJ ((//t07 1"