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_ Yk4if IVr , t APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT R� , 1601 E. HAZEL T ON AVE., STOCKTON, CA '�� f ��`� Telephone (2091 4lv8 34a-C� 1 � PERMIT EXPIRES VYEAR FROM DATE ISSUE �� �✓ (Complete in Triplicate) 4v'1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo herein des ccab d.�` Ftis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the 447L - Rules and Re, ' do c�of the San Joaquin Local Health District. G I T-1 O r I,_o4, r � W e-L-X -Z V S�= �p2 f1 r L�� 4 p u= U N i - ''` 'G,PAL O-LL- i S I City Lod' Lot Size_ b0'X� PM Job Address Owner's Name - i Address ZZ I CUSa --f ) r✓ T` - Phone 3 (970 16 �� r�^'�lie C License No.Z�.l_-Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 71 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK ?7� SEWER LINES _.__ �— DISPOSAL FLD.?loo PROP. LINEd� t� AGRICU_LTURE WELL00 OTHER WELL PITS/SUMPS v -- -- _FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u C71 Industrial .0 Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing El Domestic/Private Gravel Pack ❑ Tracy Type of Casing ,r rt" LSpecificationsdezfv G6�7�fZ Public ❑ Other n Delta Depth of Grout Seal q0 f Type of Grout�S__QG _=. I I Irrigation Approx. Depth I ! Eastern Surface Seal Installed by_._Mn '�9crar�-�y1 Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line Total length/size LEACHING LINE 171 No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line s--DISP-OSA>_=PONDS..- .❑-- . -.: .. v _ _w,Yv� - 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 andY rules and regulations of the San Joaquin Local Health District. 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." } The applicant must call for all re uired inspections. Complete drawing on reverse side. Title: � Date: Signed X FOR DEPARTMENT USE ONLY r'(0' f 4 l Appiica ion Accepted b y. -- Date Area a� k }r b Pit rout spection by Dr a Final Inspection by Date Additions! Comments:' , ❑ Stk 466-6781 Lodi -369-3621 Of Manteca 823-7 ❑ Tracy 8354385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J z FEE AMOUNT DUE AMOUNT REMITTED UK 9 CASH RECEIVED BY DATE f ERMiT'NO. 1 INFO +.EH 13-24(REV.t/ ' y I. . AA O tel." EH 14-26 -