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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 G__ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s f (Complete in Triplicate) ©'K — T S _ l (t t 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 _ ]_ � "� �/1 SCDC. City Lot Size PM Owner's Name t f ,(�..(,.�� T Address SLAn &,. "A, � ° Phone Contractor,&(, 6ddress" 5(2A(.. : µms._License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER,,❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a DISPOSAL FLD.'�' PROP" LINE J 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 Specificationsek Fl Public I-1 Other ❑ Delta Depth oP Grout Seal: Y. Type of Grout KIrrigation —_Approx. Depth I Eastern Surface Seal Installed by Repair Work Done Type of Pump Ic"r P. !�6O IdA '-State Work Done- + Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet") Installation 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 Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well " Foundation Property Line 5 SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 I 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." The applican t call for all require specti s. Co tate drawing on reverse side. I Signed X71� Title:_ Cj _ Date: M1 fi� FO DEPAkTMENT USE ONLY Application Accepted by Date ' * � Area I N Pit or Grout Inspection by Date Final Inspection by rc�,sti�it.a Date ` i Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit%Service`s'1601 E.--Hazelton Ave.,,P.O. Box 2009, Stk., CA 95201 4r r FEE r INFO AMOUNT DUE #AMOUNT REMITTED" ASH RECEIVED BY DATE PERMIT'NO. +.EH13.24'IREV.i/A5) 4 0.0' EH 14.29 r Vv.