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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he,eb made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is App Y 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. qf r Job Address �. 8 r. City �'O 4 ' Lot Size �41 PM Owner's Name r ""`'- ' I� x _ re Address a Contractor t R� Address License No._%A1- L- Phone _!634/_q ��Qr 3© TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT DESTRUCTION] ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ s DISTANCE TO NEAREST: SEPTIC TANK _L- SEWER LINES l DISPOSAL FLO.L PROP. LINE x. FOUNDATION AGRICULTURE WELL _/O OTHER WELL PITS/SUMPS .� r t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r C _,r .,,Dia of Well Casin ❑ Industrial Open Bottom ❑ Manteca�»�-•�-Diarof-Well Excavation-- - g 5� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy e Type of Casing Spe+ifications -��c� i l`1 public Ll Other FI Delta- Depth of Grout Seal Type of Grout irrigation �lApprox. Depth 1 I Eastern ;. Surface Seal Installed by - - I Repa .37 ir Work Dane ❑ Type.of Pump H:P" State Work Dane_ Well Destruction ❑ Well'Diameter Sealing Material (top 501", Depth Filler Material (Below 50') y ' "TYPE OF SEPTIC WORK: NEW INSTALLATION I1 RE i'AIF1fADDITION i_I DESTRUCTION i I (No septic system permitted if public sewer is , $ available within 200"feet") Installation will serve: Residence— Commercial_ Other !' Number of living units: '! Number of bedrooms I t Character of soil to a depth of 3 feet: I ' Water table depth �r tl SEPTIC TAMC ❑ Type/Mfg Ca y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f ' t '"y Distance to nearest: Well Foundation Property Line r . . t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell ) Foundation Property Line SEEPAGE PITS 11 Depth 'Size Number SUMPS Cl Distance to ne est: Well Foundation Property Line DISPOSAL PONDS. ❑ I hereby certify that I have prepared this pplication 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 ti Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 4, "employ any person in such manner as to become certifies subiect tor workman's compensation laws of California." Contractor's hiring or sub-contracting signature tifies the following:"I certify that in the performance of te work for which this permit is issued, I shall employ persons subj+ ect to workman's compansa- 1 'R tion laws of California." The applicant must alLfor allureuired inspections-_1693308te drawing on reverse side. Ir - Te; A Date,,— Signed X a• / 3FOf3 DEPARTMENT USE ONLY y _ -.. ., - ..,,�.. ¢ zDate Area Application Accepted by - - .A}N�+ Z * i L Date Pit or Grout Inspection by :r Dato } - Final Inspection by Additional Comments: ❑ Silk 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 (� y { ffFJI� AMOUNT DUE AMOUNT.REMITTED LA 9 ,4 RECEIVED BY DATE PERMIT NO. p ��EH 13-24 IREV. r x 51W EH t4-2a k t U