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s ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 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 Z2Al� City "Fi_� Lot Slze �Tt✓ PM Owner's NamePhone _ Address < —G -� re!S.-._._ G� E Contractor Address_ G y� fff��'" &Iys /"� License No. Phone TYPE OF WELL/PUMP: IIID NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP,INSTALLATION ❑ f SYSTEM REPAIR ❑ ] OTHER ❑ DISTANCE TO NEAREST: SEPJ IC TANK SEINER LINES DISPOSAL FLD. PROP. LINE W FOU DATION AGRICULTURE WELL-- OTHER WELL LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.,SPECIFICATIONS ❑ Industrial FI Open Bottom El Manteca 't Dia. of Well Excavation = Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy " `SType of,Casing Specifications. f I Public fl �O Yor Cl Delta Dept of G oui_Seal �. I mo `� p Type of Grout _ 1 I.Irri Irrigation g pprox. Depth l I Eastern Surface Seal Installed by _ Repair Work Done - L7 Typelf Pump H.P. State Work Done A Well Destruction ❑ Well Diameter Sealing Material (top 50') DeptFr Filler Material (Below 501 TYPE OF SEPTIC WORK: NEIN INSTALLATION- - REPAIR/ADDITION L I DESTRUCTION [ I (No septic system permitted it public sewer is i available within 200 feet.) e Installation will serve: Ridence Commercial Other I Number of living units: Number of bedrooms i Character of soil to a depth OW feet: Ad Water table depth SEPTIC TANK 'Type/Mfg u [s L Capacity A "`� No. Compartments 1 PKG. TREATMENT PLT. ❑' MethoddJof 8� Disposal r Distance to nearest: Well � Foundation� Property Line - LEACHING LINE ''( Na& Length of lines r w Total length/size Q 2 ` FILTER BED Distance to nearest: Well-4f492Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ 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. '4 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 Californ' The applicant m all for A�quired inspections. Complete drawing on reverse side. y Signed X Title: s Date: FOR DEPARTMENT USE ONLY 11 Application Accepted by SW4, Date 0 Area T + Pit or Grout inspection b Date Final Inspection by Date Additional Comments: �IF l k t ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca -7 04 ❑ Tracy 835-6385 s Applicant Return all copies to: nvironriiental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., A 95201 INFO AMOUt' DUE AMOUNT REMITTED ((,CK-H RECEIVED 8Y DATE PERMIT'NO. _ ,il ��gggppp ,�y �-_ �J i EH 13-24 IAEV.i/n 51 '� -� / !fr _ /-` �� EH 14-26 v91►V 11 (1._.r f//J a"�