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APPLICATION FOR PERMIT SAN JOAO,UIN.LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,-STOCKTON, CA S Telephone 12091 466-6781 S. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I 11 .., .« v( omplete in Triplicate) _moi C Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs application is } made in compliance with.San Joaquin County Ordinance No.549_for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address I y City Lot Size_ PM Owner's NameAddress 3 2-6 ILAL Phone I Contractor Jp� Address f License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPCACEMENT ❑ DESTRUCTION ❑ #PUMP INSTALLATION ❑ SYSTEM REPAIR' OTHER 171DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ❑DISPOSAL FLD. PROP. LINE 1 FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial '❑ Open�Bottom ❑ Manteca Dia. of,,Well Excavation Dia. of Well Casing ❑ Domestic/Private :❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public r❑ Other •1, ❑ Delta F Depth of Grout Seal Type of Grout ❑ Irrigation !--Approx. Depth ,� © Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump f� H.P. State Work Done +:. Well Destruction ❑ Well Diameter Sealing`Material liop 501 _ 'Depth ' Filler Material IBelow 501 Q TYPE OF SEPTIC WORK:I NEW INSTALLATION ❑ REPAIfi/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is D ,+ *- ailable within 200 feet.) Installation will serve: Residence_ •Commeicial._ Other ^3 s J I Number of living units: Number'of bedrooms'-- Character edrooms'Character of soil to a depth of 3 feet: a '� Water table depth F � SEPTIC TANK Q Type/Mfg `� Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line i I LEACHING LINE Cl No. & Length of lines � � �+ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ' Size � Number SUMPS ❑ Distance to nearest: Well--Foundation —= _.Property Line r DISPOSAL PONDS ❑ I ey I hereby certify that I have prepared this application andrthat the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local.Healtfi District: y i Home owner or licensed agent's signature certifies the following: "I certify+that in the performance of the iwork for which this permit is issued, I shall not employ any person in such manner as to become'subiect to workman's compens&tion law s-of,California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance 6f the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." 41 The applicant mus all for II required ' Complete drawing on reverse side.�� Signed 1 Title: Date: FOR PARTK4ENT USE ONLY -+-�-.� Application Accepted by' , - Date Area = fdc- Pit or Grout Inspection b ' Date Final Inspection by A ! ion Comments: ;i��u1 d WK q>, . C;-4- t.r o�'t ger..r?1 SSvr� eIb Stk 466.6761 ❑ Lodi 369-3621 Manteca '623 7104 FJ Tracy 835-6385 _T — App ant- Return all copies to:` nnvironnlental"Health"Permit/Seroic`es'1f>b1 E.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ZS FEE AMOUNT DUE AMOUNT REMITTED- C RECEIVED 13Y DATE PERMIT NO. INFO �S} I + EH 13-24(REV.1's 51 EI ®-� S OLS. ~ I% ?Lk, ;ZA— 1 s3 9 H 14286 i