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r _ APPLICATION FOR PERMIT A.)® SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA j Telephone (209) 466-6781 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. �f V(l✓1 ° a Job Address V City,- Lot Size PM Owner's Name 10 I-S7 Vess � Ince, Phone 009 Contractor . .� Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I f FOUNDATION 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications _ F1 Public ,.e 1 Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation " "Approxi Depth f"h'Eastern._—Sur-face-Seal-installed-by Repair Work Done;—O Type of Pump _ � ' H.P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION r I DESTRUCTION V (No septic system permitted if public sewer is My' available within 200 feet.) ~ Installation will serve: Residence Commercial_ Other Number oMiving 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. ❑ i Method of Disposal Distance to nearest: Well Foundation t Property Line - '. LEACHING LINE ❑ No. & Length of lines Total length/size . . f �ILTER BED ❑ Distance to nearest:" V11ell -Fouridationt" Property Line t EEPAGE PITS I I Depth Size _ Nunxber I SUMPS Ll 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 Di§trict. r ( Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for Fwhich.t is 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 hlnng"WI°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 w'd sfcompensa- `tion.laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X v�Title: y-� f /17 ' d� Date -:� r FOR DEPARTMENT USE ONLY' Application Accepted by Pd'Pe Date Area I ` Pit or Grout Inspection by Date ! Final 1nspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 —O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ! FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT'NO. INFO 3,5 I +.EH 13-24(REV.i i n5) EH 14-26 �"1 =0'�•�McUf'YtD-F VlGty �?UW7 ' �rpe