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APPLICATION;FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON 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 th.Q San Joe in Local Health District._._ Job Address City Lot Size v ' 4. PM_ Owner's Name ��.��a-/� C� dd ��sp�Y A ►ess �Clat/ y ��ya�iti/ / nLLe7W M1Phon-e _ Contractor's Name &C. Sn License No. Phone TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE T0-NEAREST:--SEPTIC T NK= SEWER LINES DISPOSAL FLD. . PROP. LINE / y FOUNDATION ¢ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS _- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _,..e,Dia. of Well Casing Q Domestic/Private 11; Gravel Pack ❑ Tracy Type of Casing r Specifications ❑ Public`,' ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump s H.P. State Work Done t Well Destruction O Well Diameter Sealing Material (top 5D'1 i Depth ' j-Filler Material-(Bela+,,5'0) �"'c"• - - # TYPE OF SEPTIC WORK: NEW INSTALLATION ,$' REPAIR/ADDITION ❑ =DESTRUCTION ❑ (No septic system permitted if public sewer is '"I t - available within 200 feet.l Installation will serve: Residence L Commercial_ Other Number of living units: .....,L__ Number of bedrooms Character of soil to a depth of 3 feet:' X ew,.r ve L ' Water table depth a SEPTIC TANK L ' k Type/Mfg QJX41" �y Comas I` "Capacity. �. �n No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal jx g Distance to nearest-.—Well °D Foundation Property Line 9Y' LEACHING LINE If No. & Length of lines x .S4 Total length/size" FILTER BED ._ ❑ Distance to nearest: 'Well ( ,'Foundation k Property Line I . 1 } SEEPAGE PITS ❑ Depth { Size Number SUMPS k Distance to nearest: Well 'Foundation 1 `r Property Line -4 ' t i DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in acco�danc`e with San Joaquin county ordinances, state laws, and " rules and regulations-of the San Joaquin Local Health District. 1. F Home owner or licensed agent's signature certifies the following: "I certify that in theperformance 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-coritrac-ting 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 applicant mus or all required inspections. Complete drawing on reverse side. r rh ,. T Signed ! Title: r Date: - iFOR DEPARTMENT USE ONLY Application Accepted by -_1 / ' _ Date 02 Area Pit or Grout Inspection by I Date `Final Inspection by Additional Comments: Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82:3-7104 ❑ Tracy t 835-6385 Applicant- Return all copies to: Environmental'Health Permit/Services 1001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s vl FEE: MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0.' INFO� CASH r s _ 4 H is ,Rev.,as3i 7� r 19