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i APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL H"E'ALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES'i YEAR FROM DATE ISSUED (Complete in Triplicate) . �y �ql.c, ' ��- .��+�'. !-7�i .t" "•t.'�,7k it°.r. ,"�,3�b ..V.5-. ;.;f��.�': 4 :��;i3i�+��ii' . . tta!;� ., � 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 Ryles and Regulations of the San Joaquin Local Health District. 4. a. t O ,Job;4ddress','47- '�'9 /l/, City ?Y Lot Size 4 " PM � �� ` ,Owner's Name Address "�� v s l Phone- 3td�rd - f_Svtu 9 / �y Cvntract>r (.f5- Address �Q- 76License fVo� c�c7a� Phon��0. �ra-� TYPE OF WELL'_/,PUMP: J NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ f SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 k ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy, Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx., Depth ❑ Eastern Surface Seal Installed by iRepair Work Done 0—_7ype of Pum—p H:P: State Work Done r .Well Destruction ❑ Well Diameter 5e_ting Material (top 501 uJ Depth -f Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 00 a Iy, : 11-1 available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of 1bedrooMs ' Character of soil to a depth of 3 feet t o—Water table dep!h 1QE I SEPTIC TANK ❑ Type/Mfg r`f ! Capacity____L_ No. Compartments PKG. TREATMENT PLT. ❑ T j: i F Method of Disposal I Distance.to nearest: Well" Foundation Property Line ' iLEACHING LINE [??—No. & Length of.lines J-�I Z.YU4_ _ ��'Total length/size ]FILTER BED LlDistance;to neare'si: I`�r�Well` Sa' - Foundation %U a Property Line SEEPAGE'PITS " ❑ Depth �G$'" j 'Site" . X5- Number SUMPS 0--Distance to earest: j Well, �;D( Foundation l®� Property Line DISPOSAL PONDS E) :1, p '. I hereby certify that I have prepared this application and-that the work will be done in accordance with San Joaquin cou my ordinances, state laws, and i rules and regulations of the San Joaquin Local,Flealth District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whichihispermit 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 California." The applicant t call for al quired"inspections. Complete drawing on reverse side. t Signed Title: L or t ' FOR DEPARTMENT USE ONLY I -- - "^^"'"Application Accepted"by Date --T" . Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑ Tracy 835-6385 'Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200%.Stk., CA 95201 .I FEE INFO AMOUNT DUE,' AMOUNT REMITTED CASH KO RECEIVED BY DATE!. PERMIT NO. . + EH 13-24(REY:t/e s) EH 1426