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.r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT } 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED { (Complete in Triplicate) i 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 f made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. Jab Address /t3,Sa2 d tf Cp llloz R _ City Lot Size PM - Owner's NameAddress Phone Contractor 92w"tiv�.,/ rs'a-, Address d License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRL"JCTiON O - PUMP-iNSTALLATION---❑------ ^- -SYSTEM-REPAIR-O--^s- ---OTHER- ❑,- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Cl Other ❑ Delta'- ' " Dep'tfi of-Grout'Seal Type of Grout I I Irrigation + _Approx. Depth I I Eastern Surface Seal Installed by ` - j Repair Work Done 0 Type of Pump H.P. State Work Done _ ry Well Destruction ❑" Well Diameter Sealing Material (top 50') y`"—"�-- UQ Depth ._,'F.iller_Material (1361 w 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIWADDITIONDESTRUCTION I 1 (No septic system permitted if public sewer is `p'1 2 available within 200 feet.) € T' Installation will serve:$ Residence--k Commercial T Other Number of living units: Number of bedrooms fCharacter of soil to a depth-of 3-feet:---- Water table depth ^ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f /` PKG. TREATMENT PLT, O Method-of Disposal t Q Distance to nearest: Well Foundation Property Line v LEACHING LINE No. & Length of lines T Total-length/size # FILTER BED ❑ Distance to pearest: Well sem, Foundation f0 �--'Property Line/46 s l SEEPAGE PITS .f Depth Size Number - �Y � ! SUMPS L1 Distance to nearest: Well a�� Foundation. /A f Property Line��z.9 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 r 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: "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject tow orkman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ' # / Signed Title: Date: �� G Q. ( FOR DEPARTMENT USE ONLY £ Application Accepted by Date t Area or Grout Inspection by a//lam Final Inspection Da ��; F CC�� f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 835-6385 x' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;Sik:CA 95201 s INFO AMOUNT 1 DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. iAEH13-241REV.1ie5) /{�•y� (mak ►�j7-f�? ��'f-.z�a� ?EH 14-26 _ - -•rte.,.: