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r• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _. s 1 z1601 E. HAZELTON AVE., STOCKTON, CA I �✓ Telephone (209) 466-6781 I PERMIT EXPIRES ►'YEAR FROM DATE ISSUED (Complete in Triplicate) - i 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 Rules and Regulations of the San Joaquin *Local Health District. /\Job Address vva�i(� 1 City Lot Size PM "XI0 Owner's Name q4 . Address Phone XTYPE Contract Addre 7` N 1 icense No � Phone �6 OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 t" Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing.... Specifications . P Public ,Cl Other ❑ 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 H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501i s Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW.INS,T.ALLATION I l ,REPAIR/ADDITION 1,1_.._DESTRUC.TION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence ,Commercial' Other r t Number of living units: Number of bedrooms = -' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth .- SizeJ — Number SUMPS Ll Distance to nearest: Well FoundationProperty Line DISPOSAL PONDS ❑ I 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 Di1trict. 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 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 applica must call for all required i spections. Complete drawing on reverse side. J { Signed J.Lrae.e,( � �.��,��--� Title: C 1�Lt.A-y��JL.:. .- Date: 0 oZ5/R FOR DEPARTMENT USE ONLY Application Accepted by 4ef1 qq -- � d Date f L_ Area Pit or Grout Inspection by _ Date Final Inspection by Date j Additional Comments: El 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECE DATE PERMIT'NO. INFO _ }� CASH J�(} EH 14-26 ✓V �s '/ / 7-171 8-z(v--0� ' /h4 y ,1 h ��