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} APPLICATION FOR PERMIT S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA l Q , 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 the San Joaquin Local Health District. y-s ' Job Address 7 "+ City-�% 0* Lot Size PM d! +�� . � Owner's NamePAddress Phone ' Contractor f /� e*ZW V Address-47D 64 / , 1�� f'C�_ License No.,7Z O0(�-–Phone i TYPE OF WELL/PUMP: ii NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications +� f`1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout _. �\ I I Irrigation A_Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ E � y Well Destruction LlW Well Diameter Sealing Material (top 50') V Depth Filler Material (Below 50'I -- TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR IADDITION I 1 DESTRUCTION)CINo septic system permitted if public sewer is It a ilable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Ir Number of bedrooms d Character of soil to a depthlof 3 feet: "-"'"""'^Water table depth SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments I- PKG. TREATMENT PLT. ❑ �� Method of Disposal y !Distance to nearest: Well --Foundation.Foundation. _ - Property Line LEACHING LINE ❑ IlNo. & Length of lines Total length/size FILTER BED ❑ �Oistance to nearest: Well Foundation_ Property Line i SEEPAGE PITS i I y`Depth Size _ Number SUMPS LI ';Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ li 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 ban Joaquin Local Health District. ..,._.,,.F.__ ,T= --- r --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 j certifies the fo "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cornpensa: If tion lawsalifornia. ' The app I cant st 11qui ins ctionomplete drawing on reverse side. CC ! Signed X :: Title: Q�`S� Date: II FOR DEPARTMENT USE ONLY Application Accepted by Date Area ' Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ` _G1 Stk 466-6781 — ❑ Lodi 369-3621 ❑ Manteca 823-7104 _O Tracy 835-6385 Applicant-=Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r. 0 EFEo AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT NO. �C�ASH / (f +.EH 13-24 MEV.iiR51 Yl AJl �� i� - I ` �y EH 14.20 ✓✓J �-^'s�\ p