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r„ APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL.T ON AVE.,.STOCKTON, CA Telephone (209) 466-6781 4 Z/ 3 .✓ / } PERMIT EXPIRES 1 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. ` T� -- Job Address / NN .�`� `�/y City _r]'/ yl�/yrot.Size PM T' Owner's Name --Address Phone SYS Y-�J� t Contractor /f/Is "TPaddress icense No./A/moo,/ Phone TYPE OF WELL/PUMP: NEW-WtEt 3 7\WELOREPLACEMENT ❑ DESTRUCTION ❑ t: 177 PUMP-INSTAL-LATION--i] 'SYSTEM-REPAIR`kP "" OTHER 116ISTANCE TO NEAREST:EPTIC TANK` FLW PROP. LINE"� `� I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED U6 {TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial { Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Priv late, Y Gravel Pack ❑ Tracy Type of Casing Specifications JJ Public ❑i Other Q Del Depth of Grout Seal Type of Grout ❑ Irri}ation 1 7Approx. Depth ❑ astern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done eaxx �flR I ' Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ (No septic system permitted if public sewer is.' ! I 1 available within 200 feet.) Insta lation will serve: Residence Commercial_ Other i Number of livinb units: Number of bedrooms Character of soil tD a dep h of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal \ -�`rdk Distance to neares�.��We� � Foundation Property Line sss/...��EEACHIING LINE L] No. & Length of lines Total length/size i .>FILTER� BED k ❑ Distance to nearest: Well Foundation "Property Line I SEEPA E PITS ❑a Depth d Size T r y Number SUMPS ❑. Distance to nearest: Well Foundation ] Property Line NISPO�AL PONDS ❑' V1-hereby certify that I have prepared this application and that the,work will be done inta'&dance with San Joaquin county ordinances, state laws, and` rules and regulations of the San Joaquin Local Health District/fi "A-4 '1 t dome owner or licensed agent's signature certifies the following: si certify 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the wor0or which this permit is issued, Ishall employ--persons subject to workman's compensa- tion laws of California." 7 -`�-i" N`� j The ap )[cant st c I1�f all required inspections. Complete drawing on reverse side. � �� . 00 I Signed X - Title: Da t. FOR.DEPARTMENT USE ONLY A Pica ion Accepted b Y la f date pp I � ) Pit or Grout Inspec'tion by Date Final Inspection by w -Date f Additional Comments: ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 i Applicant- Return`all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAM52(KFEE c: rPf f INFO AMOUNT DUE AMOUNT REMITTED CK It CASH RECEIVED BY DATE IT'N0. + EH 1344{REV.1/e sl EH 1426 �� da - Alf '