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-41 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA JUN 2 2 SM Telephone {209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 � �`� +-` f City ��LC3ti��Lot Size PM a .tf Owner's Name � ;.. Address - o Phone Contractor' ' to— i.t Address►b&&i.a ,_ 6_554�icense No.ia! � Phone TYPE 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing %domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public f7 Other Cl Delta Depth of Grout Seal Type of Grout --- I I Irrigation —..Approx. Depth l I Eastern i Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P.! State Work Done t -Le1if✓ ,) Well Destruction ❑ Well Diameter Sealing Material Itop 501" k n DepthFiller-Material (Below_50'). V TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION l,l (No septic system permitted if public sewer is available within 200 feet.) t n I Installation will serve: Residence_ Comme`rcial-_ Other V 1 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1>1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property 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 bri teict. Home owner or licensed agent's signature certifies tFie following: "I certify that in the performance of the work lot 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must_AQN for ail regtAF d inspections. Complete drawing on reverse side. Signed X '%�_;' ... Title: F-4— Date: - C) FOR DEPARTMENT USE ONLY '. Application Accepted b Pp P Y Date rea Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: C] Stk 466-6781 ❑ Lodi 369-3621 p 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 9WO1 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY JJ DATE PERMIT'No. +.EH 1324 IREV.i/n 5) ` r EH 14-28 / 1? k i