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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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. / ' Job Address �l d City. Lot Size. Ck9 PM Owner's Name Address ��-_C� eag ir.A2 Phone Contractor 4 Address ' lM License No. 77 " � Phone TYPE OF WELL/PUMP: NEW WELL Dl'• 'A WELL�REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ;?` SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE e Et FOUNDATION -AGRICULTURE WELL'" OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA'1 CONSTRUCTION SPECIFICATIONS ❑ Industrial EJ Open Bottom ❑ Manteca r pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ; 1 ❑ Tracy Type of Casing Specifications i 1 Public F1 Other 71 Delta fes' j 3" Depth,af Grout Sea! I i Irrigation J IY y! ;/F i, Type of Grout _ g __Approx. Depth�l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump # .iH.P� ,t State Work Done Well Destruction LJWell Diameter ''Sealing Maie.,iiial*(top 50') Depth rFillerfMaterial (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION IT REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is I i available within 200 feet.) Installation will serve: Residence-)( Commercial— Other f Number of living units: �+ Number of bedrooms 2- _r------'. Character of soil to a depth of 3 feet: 4Wi,'5�;.`�+ j � Water table depth SEPTIC TANK Type/Mfg _('c�ri.re Y-ertCapacity No. Compartments .- — _ r p.. PKG. TREATMENT PLT. ❑ -. � f,�� Method of Dis�losal Distance to nearest: Well =/�Gi Foundation7-X Property Line 110—LEACHING I-'INE �r No. R Length-nf"lines ' ?`' f - C":. , r Total length/size FILTER BED ❑ Distance to nearest 'Well �r� 1 f r N1, --,E.2_ Foundation+ ��._ Property Line ._ SEEPAGE PITS 11 DepthSize--_- Number SUMPS CI Distance to nearestF Well-J v Foundation Property Line DISPOSAL PONDS ❑ :4 I hereby certify that f 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." # j t E The applicant must call for all required inspections. o plate drawing on reverse side. Signed XI j Title: Date: ; + 1 F. DEPARTMENT USE ONLY ) Application Accepted by s Date�.:�=1 V Area Pit or Grout Inspection by t Date Final Inspection y !� G - tib - Date� Additional Comments: 4�cl lJAlf X�- -g5 9/7 9�} ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2(109, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED CK INFO _ CASH RECEIVED BY DATE PERMIT•NO. - +,EH 13.241AEV.F/HS) V EH 1428 'r��•.i r. 1 ': ��- ,.r V 7 p Io—a-"3