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APPLICATION FOR PERMIT -rill SAN JOAQUIN LOCAL HEALTH DISTRICT N 1601 E. HAZEL—I ON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � C ,� (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Q i Job Address 4 6' �Jo 6 CityZSCALWLot Size PM Owner's Name L '� U Address a/ !Q9 Sc H AL P,N�� Phon � � t Contractor's Name SU License No. l J D _ Phone � C�� TYPE OF WELL/PUMP: NON WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a Qlill� 1121 J PUMP INSTALLATION ❑ SYSTEM REPAIR ®; OTHER ❑ 1{ 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 ❑ Industrial ❑ Open Bottom W. ❑ Manteca pia. of Well Excavation Dia. of Well Casing" }/ Domestic/Private El Gravel Pack ❑ Tracy a Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation ---Approx. Depth �❑, �Eastern Surface Seal Installed by S �t Repair Work Done RL Type of Pump —L— H.P. 1 t State Work .Done ReaZr- Well Destruction ❑ Well Diameter -Sealing Material'(io -p O') Depth Filler Material fBelow 501 , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 . Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK , ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ R, ., �- , - - ,._ r,Method.of-Disposal-- Distance to nearest: Wel(' Foundation t Property Line LEACHIN6_11NEA s _ Cl No:4 Length of lines Total length/size FILTER.BED ; f; ❑ • Distance to nearest: Well Foundation Property Line SEEPAGE P,1TS F Ci.' Depth " Size t?Number SUMPS `El, Distance to nearest: Well Foundation Property Line J DISPOSAL PONDS x ❑ I hereby certify that I have prepared this application and that,the work will be done in accordance with San Joaquin county ordinances, state�lavvs, and rules and regulations of 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 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 ustII for all uired spections. Complete drawing on Aerse side.Signed ,AA •._. Date: /.S- Title: f FOR DEPARTMENT USE ONLY Application Accepted by D)byV �22� Area PR or Grout Inspection by Data Final Inspection Date K , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Peri it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT"N0. + EH 13-24(REV.10183) 10to � �`s—� EH i426