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r APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,t STOCKTON, CA I Telephone (209) 466-6781 j PERMIT EXPIRES 'YEAR FROM DATE ISSUED A f (Complete in Triplicate) L 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 Ryles and.Regulations of the San Joaquin Local Health District. Job Address 223 0 , City " Lot Size Zf PM "Owner's Name 7Deh✓to 5 .010J "� Address —7!9 � • CA10.4t-� / -, Phone j 1 !9 Q Contractor A/ '!11 ress Ila, � ,ue =Cense No`sS-"?/5-v�Phone 33% + .nO (� TYPE OF WELL7 '- "4 "fif /y VIIELL- "-:^ �"'-WELL-R1 PtA'CEMENT--C--pESTFiIIGTIOIV'❑ t t;b• 'iPUMis INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ f- �s! DISTANE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.AOO PROP. LINE' S - J _ FOUNDATION_ AGRICULT--URE WELL" -r OTHER WELL PIS$/"SUMPS LTO—_ —INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialOpen Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing �omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Z� _..._ o. ❑ Public 11 Other El Delta Depth of Grout Seal-t- --�.�,. Type of Grout ❑ Irrigation -e- ---Approx. Depth ❑ Eastern Surface_•Seal.Installed by Repair Work Done ❑ Type of Pump P H.P. ' State Work Done Well Destruction ❑ Well Diamet Sealing,Material ftop 50' Depth Filler Material f Belo ) ti w TYPE OF SEPTIC WORK: NEVV INSTALLATION ❑ REPAIWADDITION ❑ " DESTR :� UCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) fnstatlation will serve: Residence— Commercial Other Number of living 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. ❑ Method of Disposal Distance to nearest: Well Foundation ,A Property Lime LEACHING LINE E] No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation + (,Property Line SEEPAGE"PI•TS`" ❑ Depth Size Numbe •:. SUMPS S ❑ ,Distance_ to nearest: Well o FoundatProperty Line DISPOSAL PONDS . ❑'. - - ; , .�_ - — -_- -,.� �.�-►--- T I hereby certify that I hsve'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. 4. f Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not I employ•any person in such manner as to becon e,subject to workman's compensation laws of California."Contractors 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- I tion laws of California." ! J� � The applicant must calF f r A required in tors..-Co a drawing-on rever3p.side. .� Signed f f Title: } Date: vL 4FOR ARTMENT USE ONLY _ Application Accepted _ _ 9-116/ �{ i Date --- ----' Area Pit or rou I Inspection by DateF Final Inspection by Date } Additional Comments: ❑-$tk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑-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# RECEIVED BY INFO CASH DATE PERMIT"N0. + EH 1324{REV.tiBs) 1 .3.. ''oma Eµ1426' r