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;2 0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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. Job Address f q2—7t City 5L& Lot Size PM Owner's Name Address { ti 4 a Phone /, 90t Contractor Address �j3i_�O License Nu. Phone_ TYPE OF WELL/PUMP:oF NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS # ,INTENDED USE TYPE OF WELL t PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. Idf Well Casing i ❑ Domestic/Private ❑'Gravel Pack 4 ❑ Tracy -Type of Casing Specifications t `t 4 . r 1 Public Cl Others f Delta Depth of Grout Seal Type of Grout I 1 hrigation _.-Approx. Depth I I 1 Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump l H.P. _ State Work Done¢ .f Well Destruction ❑ -Well Diameter! Sealing Material Itop 501 J Depth ` i FillerWaterial {Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is Y t available within 200,eet.) ( Installationwill serve: Residence Comrrmercia Ot Ir Number of living units: Number of bedroo s Character o`f^sail°to a depth of 3 feet:' - `"i Water table depthGor— y SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments f I PKC. TREATMENT PLT. ❑' ;z,w f f a Method of Disposal t Distance to-nearest: Well Foundation Property Line 1 LEACHING UNE ❑ No. & Length of lines Total length/size UA ? FILTER BED ❑ Distance to nearest:' We11 "Foundation Property Line la dPSAL'PONOS ITS I I Depth Size�7 ?= Numbe � t IV L1 Distance to ne est: ell F ati Property Line r r. ❑ i hereby certify that I have prepared this application d that the work willjbe o e in accordance with San Joaquin county ordinances, state laws, and rules and regulations of.the San Joaquin Local Healt District. I Home owner or licensed agent's signature certifies the IqV T01 _IV Ing: " r y that in the performance of the,work for which this permit is issued, I shall not I employ any person in such manner as to become subject to'or man's compensation laws of California.?Contractor's hiring or sub-contracting signature certifies the following: "l 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." / ] t The applicant ust call for quired in ctions. Complete drawing-dn;reverse side. .^- Signed X AitllLffej Title: Date: I R.f _ i I FO DEPARTMENT USE ONLY;0/ 0. 0/ ,� ¢ J sApplication Accepted by Date Area Pit Or Grout inspection by ate` Final Inspection by DateAll S J. Additional Comments: .els ❑ Stk 466-6781 ❑ Lodi 369-362f 11 Manteca 823 04 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE f INFO AMOUNT DUE `, AMOUNT REM,tTTEfl CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(RE rims) — - s` �q�ca EH 14-26 i