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APPLICATION FOR PERMIT 1i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601,E. HAZEL T ON AVE., STOCKTON, CA ii —Telephone (209) 466-6781 i PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) r <;J, F 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 cd C16 U nr �V CiIU B ILIb- City sTK Lot Size ! PM 'Owner's Name J o D S`�` t�_ Address:' SH n1 E '� S '^ 13 O u£' Phone s�n T Contractor in 4z Address o3 S'•()Q E»aDN7 ZrLicense No.,1. 5'a 1-�s Phone i TYPE OF WELL/PUMP: i,NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Yd OTHER ❑ DISTANCE TO NEAREST: SEPTIC T - ANK� ` � SEWER LINES DISPOSAL"FLD.— PROP. LINT= 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 Dia. of Well Casing V Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i! ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation.- ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ® Type of Pump z W's H.P. 1110, State Work Done 9 E 0L 6 Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth 3 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ (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 k Capacity . No:Compartments PKG. TREATMENT PLT. ❑ '� f 'is Method,of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines' _ Total length/size FILTER BED ❑.. Distance to nearest: Well Foundation Property Line 1 II - SEEPAGE PITS ❑ Depth .II. Size Number SUMPS ❑ Distance to:nearest: ` -Well t—" Foundation. ' Property Lin-e'— DISPOSAL ineDISPOSAL 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections, Complete drawing on reverse side. p Signed X Q" r/LQ iy �� Title: Z 7�1Dai sl � ' > r F R EPARTMENT USE ONLY C Application Accepte y Date Aa ° Pit or Grout Inspec' y �I Date Final Inspection by Date 'Additional Comments; i Ll Stk 466-6781 C3Lodi 36'9-3621 ❑ Manteca 823 7104 ❑ Tracy B35-63> = `mom ` J.- 0 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAFEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE I PERMIT''NO. ^i + EH1 -241REV.7/a5) EH 1428 ff t'tiS