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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. 'HAZEL 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 /D f45- C6e M&P, IE?o920 - - City Lot Size PM =1& �/�.fkaL i T Q�77 �C��`/ �/C Phone Owner's Name � �� !Address I Contractore,!5te, 6s Address'le/f License No. -71LI Phone TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER /Uf � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1_y15ZF,� � ❑ Industrial �❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1A 2asrng ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Sa t F1 Public ❑ Other ❑ Delta Depth of Grout Seal __ Type of Grout I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 � i 1 Depth Filler Material IBelow 50'1 %!to� •�-+� Win- 1 Ttt� Z 3 > TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION {_I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation ill serve: Residence— Commercial— Other Number of living unr Number of bedrooms Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK I❑'- Type/Mfg Capacity No. Compartments ! PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Prope r I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS I Depth Number SUMPS D DistanWell ce to nearest: Faun Property Line DISPOSAL PONDS ❑ I 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 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 bec a subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 certi that in the pe ance of the work for which ' ermit is issued, I shall employ arsons subject to workman's compensa- tion laws California." f f + f i h The appy a must call to all a to- reverse si L Signed Title: Date: OR DEPARTMENT USE ONLY �]pp ; Application Accepted by i�WJA:6�� -_�— Date_ IO 97Area Pit or Grout Inspection by � ? � Date t l b "� Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ 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 -` GK` RECEIVED BY DATE PERMIT NO. INFO C/ASSHj - + EH13-24(REV.I/x 5) Z��t�� , � �t�y"7r 10/ V907 6740q�V3 EH 11-26 t