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t l APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. ll }� i I Job Address Z R V ! r`-� City cLot Size PM i Owner's Name Z OS.__-k. Address Phone l ConlractorLJ`!f'S L 1 !7 1�r1A, �_Address License No. &Wphone L S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ - OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER,i 1fE PITS/SUMPS INTENDED USE ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind'ustrial • .0'Open Bottom ❑ Manteca Dia. of Well Excavation--' Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications Jq f'1 Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material {Below 50'] TYPE OF SEPTIC WORK: NEW INSTALLATION I.i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other " v. Number of living units: °' Number of bedrooms Character of soil to a depth of 3 feet: a fQ Water table depth ` t 'SEPTIC TANK ❑ Type/Mfg' o r'r;i-f-�i Capacity No. Compartments k PKG. TREATMENT PLT, CIj�Y fi �f - ;t1� S `ry ' ! Method of 015po/s�al Distance to nearest: ell Foundation /_`0 Property Line LEACHING LINE R2�t'Length of lines' TotaLierigth/size f` ., a I A FILTER BED r i]_Distance to nearest: t Well Foundation Property Line SEEPAGE PITS 1 Depth L t Size _ Number 12, r x ' SUMPS {.I Distan to nearest: elk Foundation DISPOSAL PONDS ' © I hereby certify that t have prepared this-application and that the work will be d^ne in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. } 1 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�� employperson in such manner as to become subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature certifies t wing: 1I cert 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 Cali �CIL " The applicant m t al re dire 'n o p to r wing on r rse side.14 ��Signe: Date: x jqwDEPARTMENT USE ONLY 4 r . . a Application Accepted t " Date Area i r Grout Inspection by - "" 6aTe Final Inspection b Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECKV INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE(+� /PERMIT"NO. + EH 13-24[REV.1 i H 5) Lam/ 0-3)