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t APPLICATION°FOR PERMIT SAN JOAQUI'N LOCAL HEALTH DISTRICT U J 1601 E.. HAZELTON AVE.,;STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Districtrr; : 3. � s—ms's.• Job Address W City Lot Size PM Owner's Name �y Address 3 36 Phone Contractor 1?07W QadZT-k Address �`�'�da`s��3 f7-leZO dg License No._ 6 / Phone��Z6/ TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 Casin I L Specifications E] Public ❑ Other ❑ Delta Depth of Grout Seal' __ Type of Grout p ❑ Irrigation --Approx. Depth ❑ Eastern ` � g Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done (� II Wel! Destruction ❑ Well Diameter Sealing Material {top 5011 I Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RRP_AIRI.ADDITION_ ESTRUCTfON- o septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial!2 G¢Cs�sP,Other �� E r�C 7V'y,r Q�vZy ) Number of living units: —_/ Number of bedrooms�_ rT .. Character of soil to a depth of 3 feet: Water table depth �f SEPTIC TANK .. Type/Mfg — Capacity Z �U No. Compartments Z- PKG. TREATMENT PLT. El Method of Disposal Cf-fr";" Distance to nearest: Well_! .- Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ;I FILTER BED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ___.._,..,._..DISPOSAL.PONDS_, ' p I hereby certify that lha+iepreparedths applicaion',id 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."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 c000r all requi d inspe . Complete drawing on,reverse side. Signed Title: Date: FOR DEPAR ENT USE ONLY Application Accepted by Date 7 _16 -910 Pit or Grout Inspection by Date Final Inspection by �y Date Ad ''onal Comments: tk 466-6781 ❑ Lodi 369-36221 ❑ Manteca 823-7104 ❑ Tracy 835-6385 { M App ant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 " FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO CASH DATE PERMIT'NO. dQ - � EH1O 3-24IREV.tie 51 EH 14-28- z J