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f � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091466-6781 t. . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hepeby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is r 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. t Job Address&I /! �� /� � �l i. City.�I V'CA Lot Size y PM 4� C CJ_,Qi9/G !7 aid r� �Address '`�� W_ �•�/�/t/I /� Phone — / Owner's Name ContractorAddress ,ter /� 1�1if.�Cd ' mid License No. Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .PROP. LINE 'F&ONDATION' AGRICULTURE WELL! OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of Well Casing Jd Domestic/Private ❑ Gravel.Pack ❑ Tracy Type of_Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Fr Repair Work Done ❑ Type of Pump H.P. State Work Done ZIV52:"&l1 Well Destruction ❑ Well Diameter Sealing Material {top 50'I ,T � GffL0.2/�J Depth ,1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 � available within 200 feet.l Installation will serve: Residence., Commercial� Other Number of living units: — Number of bedrooms ia: I Character of soil to a depth of 3 feet: Water table depth N SEPTIC TANK ❑.'Type/Mfg Capacity. No. Compartments 1 1 PKG. TREATMENT PLT.'❑ +++ [,�� Method of Disposal ti]4 l� 1 Distance to nearest �llllell� Foundation Property Line 1 k LEACHING LINE ❑ f No. & LengtFi of line Total length/size. *. FILTER BED ❑ Distance to nearest: Well Foundation Property Line rl SEEPAGE PITS ❑ ; Depth" Size Number 4 :. .SUMPSu,.._ ❑_ Disfance to.nearest: -- Well Foundation -'Property Line DISPOSAL PONDS`, ❑ t 1 hereby certify that k-N6ve.prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations�6f 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 applicant must lt'jo" all re it inspections. Complete drawing on rovers ide. GZ>� Signed X �r, Title: �//� { FOR DE FITMENT USE ONLY kApplication Accepted by t Date Area Pit or Grout Inspection by Date Final Inspection by Dare Additional Comments: } ❑ Stk_466-6781_❑.-Lodi�369;3621—D..Manteca,.-823-7104.w.. EJ Tracy--.835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., IrPw9�1 FEE AMOUNT DUE AMOUNT REMITTE6," �`AC K 4* < RECEIVED BY DATE PERMIT'NO. F INFO t + EH 13-24(REV. 115) S` ��l ��'C�� —594 .. EH 14-26 _