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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT �]� = �t 1601 E. HAZEL T ON AVE., STOCKTON, CA Y� X_ ) 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. ,/� Jo1riJob Address 4 �-�0.�-O, r� City t '= "wL Lot Size PM Owner's Name Q �Jt "0"7 ddress ;_T �-L� �_ ' �D� Phone Co lractor Address Jt� £�4 License No. Phone—W-4-2-:9- TYPE hone_ -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well Casing © Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications f'1 Public n Othe it Delta'� Depth of Grout'Seal " Type of Grout ! I Irrigation -Apprax. Depth l I Eastern Surface Seal Installed by Repair Work Do Type of Pump H.P. State Work Done _ PA Well Des ction ❑ Well Diameter Sealing Material (top 50'1 Depth+ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is 4. vailable 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 R LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance�to nearest:- L� Well Foundation Property Line SEEPAGE PITS i I Depth, Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m st call for all required ins ' tions. Complete drawing on reverse side. /�I igned X1. ✓ ek,r a''� Title: "tR l Date: d � FOR DEPARTMENT USE ONLY 1 Application Accepted by Data Area � t Pit or Grout Inspection by Date t i Final Inspection by u�^^ Date �7 Additions! Comments: Bf ��I- _ �� _ ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca a23-7104 Cl Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 ! 1 t I INFO AMOUNT DUE AMOUNT REMITFEE TED CK RECEIVED BY DATE PERMIT'NO. +.EH 13 (RE tin5l Ob EH 14- � I uKXV