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>' yr APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA *� y Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 t made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address J2 3-5 Lt..D a n Q - _- City 170 C Xtodot Size PM I Owner's Name a Address 5 3 5 L lLu. Q Phone gig, ry S 4 o5 z x Contractor 1 t�f _Address License No. Phone j TYPE OF WELL/PUMP: NEW WELL ❑ X ` WELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER 171 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �1 FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing - _ Specifications — M Public f I Other F] Delta 4 Depth of Grout Seal Type of Grout I I Irrigation Approx.:Depth 11 Eastern Surface Seal Installed by - Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1'_ Depth Filler.Material-(Below 50') TYPE OF SEPTIC WORK: NEW iNSTALLATI0 EPAIR/ADDITION I.I DFSTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.l 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size _ Number ? SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "t 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 must call for all required inspections. Compiee/te drawing on reverse side. .Signed X �J vt• /Z�JN-I'tl..-- Title: d'A�.!h4a ?.d Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Z J Area Pit or Grout Inspection by f ] �IJatef ® Final Inspection by/ � jDate Additional Comments: _2l 73143 Zk� '��'"�' L 6&wd er 14!1 Gam' "`— ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 0 T cy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II FEE k INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED^y DAAT.E-�, PERMIT-NO, f -EH 43-24(REV,i/RS) EH 1429 ��JJIYYY w , -