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I ar APPLICATIOWFOR PERMIT l_ SAN JOAQUIN LOCAL HEALTH DISTRICT 4— I 1601 E. HAZE T ON AVE.,.STOCKTON, CA Telephone 1209► 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED , (Complete in Triplicate)_ t t, 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. } �" _ 5' Job Address / � �` GZ 2.7F/l/ City : Lot Size 7.5 () PM �nsk�( Owner's Name , r ss '-�7 ( G�t,.GCG�_U'�/� �--,•Phone tee.- contractor— -. _AddtessLicense No. Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SMl�PS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typeof Casing Specifications t ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 3 Sealing Material (top 501 -�-- --Depth Filler Material (Belou4 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ !REPAIR/ADDITION_.❑ DESTRUCTION No septic system permitted if public sewer is v _ a ilable within 200 feet.) , n Installation will serve: Residence Commercial_ Other Number of living units: Number'of bedrooms # Character of soil to a depth of 3 feet: E Water table depth SEPTIC TANK ❑ Type/Mfg` Capacity 1No. Compartments PKG. TREATMENT PLT. ❑{ �',�) ) Method of Disposal t Distance to nearest: WellFoundation Property Line 1 (� I LEACHING LINE ❑ ` No. &Length of lines w R '� V �'" T to ai length/size } I FILTER BED ❑ Distance to nearest: Well i i Foundation Property Line I \ SEEPAGE PITS ❑ Depth Size — Number f. SUMPS ❑ Distance to nearest: WellFoundation Property Line DISPOSAL PONDS ❑ 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 Localz4'lth 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 sucfi-manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I Lcertify that in the performance of the work for which this permit is issued,I shall employ person's Oct to workman;s compensa- tion laws of California." t J I The applicant must call for all required inspections Complete drawing on reverse side. Signed X �. �s]/ !t Title: __ �f lclll/}�r Date: -7S7 4 r FOR DEPARTMENT USE ONLY Application Accepted by Date —e Area Pit or Grout inspection by Date Final Inspection b Date I Additional Comments Y�� .$5"fl rx�d6, , 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 6385 J �� h Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 !� sIrFEE �� F INFO AMOUNT DUE AMOUNT CAS CAS RECEIVED'BY DATE PERMIT NO. EH 13-24( �� `^� � � EH 1428