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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,;STOCKTON, CA Telephone {209} 466-6781 1 PERMIT EXPIRES 1 YEAR,FROM DATE,ISSUED t i (Complete in Triplicate} r.. 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin 1 Local Health District'' ' 6 Job Address d3sgo City(jjLot Size PM Owner's Nam Address /-730 d • Il ` Phone "d 7 Y T Contract W Address P�8 U�71 1�7 License No.a �-2 Z4 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑' , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑I t�f 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. pf Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta }Depth of"Grout Seal" � Typelof Grout l — ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 3 Repair Work Done ❑ Type-of Pump H,P. i State Work Done_ ( n LJ W Well Destruction ell-Diameter Sealing Material (top 50'1 - v r Depth (ler M (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ PAIR ADDITIO Er DESTRUCTION ❑ INb septic system permitted if public sewer is Q A 3 f x* available within 200 feet.) Installation will serve: ResidencelCommercial sR: 0Otfie1 1 9 Number of living units:Z Numble4s�r�flbe_�d�rpoms ' „ Character of soil to a depth of/i feet:' !.r' Lr$ I Water table depth— SEPTIC epth SEPTIC TANK ❑Type/Mfg Capacty; — + No- Compartments. PKG. TREATMENT PLT. Q ; u I, Method of Disposal. / �:� 1 y � Distance to Barr est: 17.Vell'' Foundation r Property Line i 1 i fT f '7 LEACHING LINE 1111,�'No. & LengtF\6f lines Total length/size FILTER BEd ❑ Distance to nearest: Well'/?; -Foundation Property Line�s l SEEPAGE/PITS y' V Depth c[.;� _Size { Number 01 I ~ r' SUMPS ❑ Distance to nearest: Wells I04r- Foundation Property Line DISPOSAL PONDS ❑ t ,I by ereby certify that I have,prep req this app cat on_and_th�at-the work-will-be done,in accordance with San Joaquin county o4 inances, state laws, and 'rules and regulations of the San Joaquin Local Health D"strict. ! , Home owner or licensed agent's signature certifies the following: "I certify'thzft-in the p—e orman�ce ofthework for which this per_mit is issued, I shall not 'P=M- employ any person;in such manner as to become subjectto.workman's compensation laws of California."Contractor's hiring or sub-contracting signature 'F cf the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion the following:"I certify that in the performance o t-ion laws of California." t i e The applicant mu t call for al equir dein'spections. Complete drawing,[on rave rse'_s`e:� 1 Signed X - ,r.Title: �! r Date: q Igo 01 FOR DEPARTMENT USE ONLY ! Application Accepted jiy T! {! Date Area 'Zilt or Grout Inspection by Z Date Final Inspection by Date Additional Comments: . I ❑ Stl< 466-6781 i, ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I f FEE ' 1 INFO AMOUNT DUE AMOUNT REMITTED CC ASH RECEIVED BY DATE PERMIT-N0. �) r r + EH 13-24 ME -7O �(�V. j - � I � � _ �r(`l-� 1 A-71- EH 14-26 G ( `1(' ; ( L+ i