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APPLICATION FOR PERMIT a3 w+ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r Telephone (209) 466-67$1 �_c 6'i—_ 3 YY a PERMIT EXPIRES 1-YEAR FROM DATE ISSUED {Complete in Triplicate) �y Application is heteby 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 C6unty Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ) j {� )(Job Address y� V t^ sov �lie- City Lot Size S�x�V v PM Xbwnet's Name V Address 'Trio 'i Phone t G )L ,0 `5l`0 Xontractorrp,641 1I& Ley/ �N lel t]dress / l� '�J License Nr Z� Phone 1! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION EI SYSTEM REPAIR ❑ OTHER ❑ h,� DISTANCE TO NEAREST:.SEPTICrTANK SEWER LINES DISPOSAL FLD. PROP. LINE lit FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 171 Public 17-1 Other FT Delta Depth of Grout Seal Type of Grout _. I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.P. 1 State Work Done_ Well Destruction ❑ Well'Diameter Sealing Material (top 501 . Depth 1 [ Filler Material (Below 501 TYPE OF,SEPTIC WORK:�NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Rtf'sidence Commercial_ Other Number of living units: iE� Number of bedrooms Characterfof soil to a depth of 3"feet Water table depth K SEPTIC TAN-K ❑ .,Type/Mfg � Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal pistance;to nearest: Well ,Foundation PropertyLine ` LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distanceito nearest: Well + Foundation Property Line I 1 C SEEPAGE PITS { I Depth Size Number SUMPS ❑ Distancetonearest: Well Foundation Property Line DISPOSAL POND$ ❑ 1 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. 1 shall not employ any person in Ouch 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 mu fl for all quired inspections. Complete drawing on reverse side. aa �` �/► Signed 7C Title: `""' Date: FOR DEPARTMENT USE ONLY Application Accepted by Date /� Area Pit or Grout Inspecti n Date � Final Inspection by `_ Date d Additional Comments: Q ij`"'� 4 ?) 1, AV\ ❑ Stk 466-6781 C Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Enviro{{nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE. AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24(REV.1/d 5) 1 1�16EH 14-2$ �d Z