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�'f F� T Y A - .� f• APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone {209} 466-6781 M PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t - *F. (Complete in Triplicate) :h 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 QL6 5D O City L� Lot Size PM ati Owner's Name o� �5 �ce_z4 ` m g Address C-A – Phone s5z` 9.5 i Contractor EXe� p-+ Address Lk t 'le Cti cense No. Phone( "9--OYo 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 PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . Dia. of Well Casing ❑ Domestic/Private )k Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ¢-0,14- LJ --0,14- ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (7 available within 200 feet.] Instaltation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg \ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal cp I Distance to nearest: Well Foundation Property Li•�y}e A �� 4 LEACHING LINE �� ❑ No. & Length of lines __- � � Total len g th/size F FILTER BED ❑ Distance to nearest: Well Foundatidn Property Line '`r 1 { SEEPAGE PITS ❑ Depth Size NumbeP SUMPS ❑ Distance to nearest: Well FoundationPropFVW*DISPOSAL PONDS ❑ MS f /E` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cou ty&rdinarices, state laws, and t 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." r w 1 The applicant must call for all required inspections. Complete drawing on reverse side. 1 iAJ nU d-,.0Cl d4 f Signed Title:-, N4"o 4�A -- Date: �r 2 FOR DEPARTMENT USE ONLY 5� �� 3 0 5S Application Accepted by Date Arma y Pit or Grout Inspection by Date Final Inspection b Dates ` er Additional Comments: 4 ❑ Stk 4666781 CJ Lodi 369-3621 ❑ Manteca 823-7104, ❑ Tracy Applicant- Retum all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9521 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO R a EH13-24 4REV.l i a si 3 v� i7 ��/�' /t � EH M28 _ 0&1 Y