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F APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 '� �7J Q�• PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' HFAL�� (Complete in Triplicate) ��;�RD�r�tit"5�� 1C�� Kiri-d N) I� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her his application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Reg lations of the San Joaquin Local Health District. 1 V�i City��A Lot Size PM Job Address �,(� �f} ` �f r f� Address v"' ` _v t ''` Phone ` ✓�'7 Owner's Name j'} / ddre f y Imo') /� -� IF Contractor or �UL�ddress �►'T �-�+e U License No. �D Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X ellvnbrn DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL __ PITS/SUMPS i WIJ� "_`INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPfCIF1CF�TIONS it ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation'llyk Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack •Tracy Type of Casing Specifications F] Public Other MVJ ( i Delta Depth of Grout Seal 1�C'reT7{• Type of Grout 0( ��_Approx. Depth l I Eastern Surface Seal Installed by - I E Irrigation y,).)_, F 15 (' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material [Below 501 i � TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIR/ADDITION 1-1 DESTRUCTION l I (No septic system permitted if public sewer is If 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 4 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ -No. & Length of lines. Total length/size FILTER BED O Distance to nearest: ' Well Foundation Property Line ' Number Size _ SEEPAGE PITS I ! Depth _ SUMPS O Distance to nearest: Well Foundation Property Line f�'� y-�DISPOSAL"PONbS' ❑" I hereby certify that I have prepared this application and that the work will be done rin accordance with San Joaquin county ordinances, state laws, 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 ap rcant us call_fgcTal4 r i ed inspections. Complete drawing29Z:�__ Signed _�+/ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Dat /� Final Inspection b+� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ] '^� ♦ EH 13-24(REV.1/H 5) QQ 3�. �' L !CJW. �• Y" '^�� l7��9 Y! EH 14-26