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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E(\HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y - wl (Complete in Triplicate) 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 Distrix. s 1 -7 s N Job Address p �� -- City Lot Size PM _ a Z g Address 4Q- �k ��• 4/A/,QWPhone �-� 7 Owner's Name pZT� — Contractor !�5 ;y,$Address&Z 14-YAGpY .ems License No. Phone TYPE OF WELL'/PUMP: NEW WELL ❑ WELLJIEPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION _ SYSTEM REPAIR fir OTHER ❑ t DISTANCE TO NEAREST: RP�4C TANK sEWERrLtiNEs DISPOSAL FLD. PROP. LINE, / ( FOUNDATION _. AGRICULTURE WELL OTHER WELL PITS/SUMPeW f INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. Industrial LJOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing d `E Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing L ---__ Specifications GRUls+� f ❑ Public ❑ Other 0 Delta ~. Depth of Grout Seal 529 Type of Grout If 60 Ale ❑ Irrigation --Approx. Dept ❑ Eastg��/n/,,� Surface Seal Installed by , OD.Q/1?�Z / 5 LU Repair Work Dine �❑ Type of Purgp��1#M_7' t.P. State Work Done 11V Well Destruction 1171 Well Diameter Sealing Material (top 50') _ < ,A�-�' E Depth Filler Material (Below 501 _R—Z7l`! "! elog rZA-)d r" TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is availale within 200 feet.)serve: Residence._—Commercial.-� Other, JZ(A ng units: Number of bedrooms � Character of soil to7a-depth-of-3-feet: ►Nater table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments' I PKG, TREATMENT PLT El `r Method of Disposal " kDistance Diso ne to . W611 Foundation Property Line tr LEACHING LINE ' ❑ No. & Length of lines I Total length/size r C. FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS y j ❑ Depth Size Number ) PSUMPS 5 [IDistance to nearest:- Well Foundation Property Line DISPOSAL PONCES ❑. I 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San'Joaquin'county ordinances, state laws, and ! rules and regulatiolnslof the San Joaquin Local Health District. ' 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 bf,California."Contractor's hiring or sub-contracting signature certifies the follovWlg� "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compense- tion laws of Califortlia." y - The applicant mu call for all required inspections.,Comdlate drawing on reve ide. /1 Signed Title- �-- Date: 2 2 dlAe7- '" .{,r Wil• �� r ~F ]il l��s� �I� FOR DEPARTIVIFNT USE ONLY Application Accepted by Date `'` Area Pit or Grout Inspection y Date Final Inspection by bate Z Additional Com enlil - ❑ Stk 466-6781 I ❑ Lodi 369-'j621 ❑7AanteA 823-7104 ❑ Tracy, 8k-M Applicant- Return all copies to: Environmental.Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 rJ FEE AMOUNT DUE AMOUNT REMITTED CK ASH -.-AEG EIVED BY DATE PERMT'NO. INFO ' + EH 1324REV. 5) ° � 1V�� I '�b� . 11114 ' S t/ t