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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E. HAZELTON AVE., STOCKTON, CA l Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR M1FROM DATE ISSUED t (_,Complete in..Triplicate) i 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. L _ - �C I Job Address• Cityl`�-� i7 Lot Size PM Owner's Name V, w�i i►S - Address zo<ME Phone ) Contractor.e4-1 S Address 461� License No. 73 Phor 3 T_T TYPE OF WELL/PUMP: NEW WELL' WELL REPLACEMENT ❑ DESTRUCTION ❑ ; PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i I DISTANCE TO NEAREST: SEPTIC TANK f'LO SEWER LINES DISPOSAL FLDJSJ PROP. LINE _G0 j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing Domestic/Private 5�'Gravei Pack ❑ Tracy Type of Casing r- Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal S a. _ Type of Grout CAMc t' El Irrigation _ _'LS�___Approx. depth ❑ Eastern Surface.Seal Installed`by'+ Repair Work Done ❑ Type of Pump [`T- H.P-.— - - Siate Work Done0 W V-4-l ---- — Well Destruction- .L] WeH Diameter—_ Sealing Material (top 50') Depth4- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 4-- 1 ^—.."v ---'^'� " , 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: ' t` - I F Water table depth SEPTIC TANK ❑ Type/Mfg = Capacity W No. Compart-Ments PKG. TREATMENT,PLT!❑� ; i "" '� t j . Method of Disposal Distance to nearest: Well Foundation Property Line I 4 R LEACHING.LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line " SEEPAGE PITS ❑ Depth Size Number E ' 1 SUMPS r ❑ 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 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."Contractors 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 required inspections. Complete drawing on reverse side. �1 Signed Title: Ot-j*_- Date: S" e FO DEPARTMENT USE ONLY Application Accepted by Date �� "4 Area Pit or ro Ins Q �(� pection by Date / Final Inspection by�~ Date_73 r ! `l Additio al Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-241REV.tia51 Io's b3 D 7� Jr�l�v EH 14-28 0 _ 1,"