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APPLICATION FOR PERMIT lie SAN JOAQUIN LOCAL HEALTH DISTRICT ) 1, 1601 E. HAZEL T ON AVE., STOCKTON, CA tJ � Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ,, (Complete in Triplicate) �U� " 1Q�9 r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the V�r r 1n described.Q�TT�his application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the 1#t11��jC t,*n Joaquin Local Health District. RMITISE S Job Addressl3 Y-6-01 City Lot Size PM Owner's Name 2i,&,=-t : S—e -' ' "':~�r-r-dress 3- 6(a Cl �] r 4-s�- g=L. Phone rra f f �,e � �� Contractor Address License NoPhone,,A-�'q(° a S- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -: SEWER LINES DISPOSAL FLD. 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 lr7Domestic/Private "-O.Gravel.Packt ❑ Tracy�1 Type of Casing f Specifications f'7 Public a ❑ Other ❑ Delta Depth of Grout Seat I '� T Type o1 Grout I I Irrigation y --Approx. Dept I 1 Eastern T; Surfa a Seal Installed by _ Repair Work Done ie- Type of Pump H P. Stat i Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') F Depth Filler Material (Below 501 c Y TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION { I (No septic system permitted it public sewer is available within 200 feet.) nstallation will serve:, Residence Commercial_ (3t6er l Number of living units: Number-of bedrooms r ,! 'a,l l 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 ❑ e No. & Length of lines R_ Total length/size FILTER BED. ❑ �Distance to nearest: Well Foundation ' Property Line s - SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation ,Property Line DISPOSAL PONDS ❑ 1 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 y rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 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 ust call for all required inspections. Complete drawing on reverse side. _ 4 t / Signed / /�—Title: 1� t Date: 1�'r1¢ i I F. DEPARTMENT USE ONLY Application Accepted by M Date i 7—�y1 k7J— Area Pit or Grout Inspection by Date Final Inspection by 7�� Date Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 335-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P,O, Box 2009, Stk., CA 95201 IN AMOUNT DUEL AMOUNT/REMITTED CASH CK A RECEIVED BY DATE PERMIT NO. a,EH 13-241REV.I/K51 3s�ao (�(rl �� 5� EH 14-26 - "'--- ��,bbb i