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J APPLICATION FOR PERMIT L� SAN JOAQUIN LOCAL HEALTH DISTRICT NIJ`UJ j 1601 E. HAZE T ON AVE., STOCKTON, CA i! Telephone (209. -6781 UU PERMIT EXPIRES 1 YE fi M DATE ISSUE© {Complete in Icate) 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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. .f, a .T='�'Addresss City Lot Size�fl�t9 xl00 PM Job Address r jPhone Owner's Name GaT� License No Phone Contractor Ae-.Ige �� Address 4 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK EWER LINES 2 - DISPaSAL FLD. PROP. LINE FOUNDATION A (CULTURE WELL'' WELL• PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM A A CONSTR ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel.Pack ❑ Tracy ype of Casing Specifications Fl Public ❑ Other ❑.Delta epth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth l I Easte S ace Seal Installed by - V Repair Work Done Ll Type of Pump State Work Done Well Destruction ❑ Well Diameter Sealing Materia (top 50') ;._,_..Depth ._ —Filler Material.(Below.50'1_r_... ,. TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIWADDITION LI DESTRUCTIO INo septic system permitted if public sewer is available within 200.feet.) Installation wih`5etvt: "ResidenceCommeraal l Other.. Number of living units: _V Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compaitments PKG. TREATMENT PL•T. IJMethod of Disposal Distance to•neaiestr ti Wel! Foundation �� `� Property.Line: f :.ice LEACHING LINE LINo. & Length of iiniss, ,.'' d' Total length/size FILTER BED j ❑ Distance to nearest: We11 ��_ FoundationProperty Line SEEPAGE PITS l 1 Depth t"�..x 'r.z1 Size i ' Number SUMPS Ll Distance to nearest' :, Well' foundation , Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the wo_r_k.w'itj'yb_e done in_accordance with SanLJoaquin county ordinances, state laws, and rules and regulations of the San Joaquin'Local.Health District. Home owner or licensed agent's signatureicertifies 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 taws of California." Contractor's.hiring or sub-contracting signature certifies the following:t"I certify that in the performance of the.work for which this permit is issued,I shall employ,persona-subiect to workman's compensa- tion laws of California c The applicant must call for all quired in specttons. Complete drawing on reverse side. Signed X' C _ wx*" Tifle: I. �f_-d* .. bate: " " I v.. "F DEPARTMENT USE ONLY Application Accepted, _ Date °'( " Area 3 11 i Pit or Grout lnspectiol by Date Final Inspection by Datr Additional Comments/ - ' ❑ Sik 466-6781 (.❑ Lodi 3&9-3621 ; i ❑ Manteca 823-7104 ❑ Tracy 835-6385 l Applicant. Return all copies to: Environmental Health Permit/Services:1601 E. Hazelton Ave., P.O Box 2009, Stk., CA 95201 t »w.,.a. ...- --..`.-+. t- ._.._. -.:a•+�•-.W r.t-- �.....,.-..�..---.r-�-e,►-..w-+�..---�"a�5` -.-",-.^p.�+..�rt"""n•-.�-....— ..-.-.i._ .. }jg\�J` FEE AMOUNT-DUE------ AMOtiNT REMITTED "'""'"'RECE1VEi] BY'"' ""'"DATA "'`' yPEFiM1T'Nj/w INFO CASH 2-17- � �• (� EH 13-24(REV. t/xs) � F .s Z�O; U7— EH 14-26 211- _ is