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r--" APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—1 ON AVE., STOCKTON, CA Telephone 12091 466-6781'.) .,t a 4 PERMIT EXPIRES 1 YEAR FROM,DATE:ISSUED . (Complete in Triplicate), -„J 2, -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 t 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. "YS Job Address City Lot Size PM %Sk u ' 8 3,30eM Address �LT1 7rQeJfPhone Owner's Name Contractor Address id License No. Phone �Il TYPE OF WELLIPUMP: NEW WELL ,X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IO DISTANCE TO NEAREST: SEPTIC TANK J2�-t SEWER LINES DISPOSAL FLD./�'f PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS — INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I �E - ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private )(Gravel Pack Tracy Type of Casing PC Specifications EJ Public ❑ Other 11 Delta Depth of Grout Seal U Type of out ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by rRepair Work Done ❑ Type of Pump H.P. Sta/t/pW_ o�,Done Well Destruction ❑ Well Diameter Sealing Material (top 501 y � Depth 105,i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installati�i wserve: Residence_ Commercial_ Other Number of living ung . Number of bedrooms Character of soil to a depth o et: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines otal length/size FILTER BED ❑ Distance to nearest: Well Foundation rty Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line h: 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 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 applic m t t call for all required ' spections. Co plate drawing o /verse side. Signed Title: y /"L (-ate-/ Date: FOR DEPARTMENT USE ONLY 4 Application Accepted by Date rq� Area o Pit O G ut spection by Date !—Zkx Final Inspection by Date Additional Comments: " ❑ Stk 466-6781 ❑ Lod 369-3621 ❑ Manteca 823-7104 ❑ TrIcy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _ IFEE NFO AMOUNT DUE AMREMITTED CK RECEIVED BY DATE PERMIT N0. [,OUNT+ EH 13.24(Hl:v.4/B5)EH 1428