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f APPLICATION FOR PERMIT r SAN JOAQUIN [ I_ HEALTH- 1601 E. HAZE.T ON AVE., STOCKTON, CA r Telephone (209) 4ECEM PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S%�,d0� (Complete in Triplicate) �� y��4 Application ispheieby made to the San Joaquin Local Health District for agpermit to construct and/or insta ",, �`�cribed.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump an e� ��egulations of the San Joaquin Local Health District. O"oNr y1 n Job Address iI!% YF-r .4��I. ^rY - City G �'�Lot Size PM Owner's Name, 5�� y� �rAddress /-� r/ �r�C�/f'� � G _ Phone OF 00.1 Contractor Y ` ' 4 "" &el� Address �ir-t License NJO� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ��r SEWER LINES 14-r-1 DISPOSAL FL❑. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION, ndustrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 21&avel Pack ❑ Tracy Type of Casing lmo-<, Specifications / 4F-*-?— ("1 Public ^W&W C] Delta Depth of Grout Seal .l_,-d,, Type of Grout E� _ 11 Irrigation —,Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump �?yq H.P. rr State Work Done Well Destruction ❑ Well Diameter Sealing aterial (top 50') F Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is r available within 200 feet.) pI Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms depth 9 Character of soil to a depth of 3 feet: Water table de P SEPTIC TANK ❑ Type/Mfg Capacity 14PApY MENT r PKG. TREATMENT PLT. ❑ tl�piso�l Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ENWROMA"r`1 1 ''EALTH PFRAA \nrrr -- SEEPAGE PITS 11 Depth Size Number y; 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. i 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 i certifies the following: "1 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 st call f r red inspections. Complete drawing on reverse side. ` Signed X Title: /.r r Date: �� g l FO RT SE ONL Application Accepted by Date Ar 33 Pit or Grout Inspection Da Final Inspection b Date Additional Comments:-„1 E�"r 67Z' L1p;O�l � 1 ❑ a0teca M-7104 ❑ Tra et9- Applicant - Return'all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T FEE AMOUNT DUE AMOUNT REMITTEDK RECEIVED BY. DATE PERMIT-IVO. INFO 7 r.EH 13-24IREV.i/n5l `O� 00`7)p e`�� 6oA EH 14-2e F