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i . APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' F 1601 E. HAZEL T ON AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED 3" n y�,,�,•� {Complete in Triplicate). anx 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. kE1 Job Address i2� ` f1 /Ul AJ t• Qy e� City Lot Size.�� Xvs-6 PM f Owner's Name 4J 0 AJ ,-A ---"Address +,YCL"i"Yr @, _ Sb s / _ Phone a Contractor I �!'S3 nAddress _&4 P License No. Phane_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL: REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ __5Y- TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL ``"'PROBLEM AREACONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ MantecaDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack i ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ' ❑ Eastern Surface Seal Installed by ! Repair Work Done ❑ Type of Pump H.P. i - State Work Dane - Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material Ieelow 50') I �J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (Nosepticsystem permitted if.public sewer is ([� -,available within 200 feet.) �• Installation will serve: Residence_ Commercial_ Other t' I y Number of living units: Number of bedrooms f # I 1e b . Character of soil to a depth of 3 feet: - - Water table depth '" i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line M« LEACHING LINE ❑ No. & Length of lines Total length%size FILTER BED f ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth ' Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS F7 I hereby certify that i have prepared this application and that the work will be done inaccordancewith 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 r em to an g g g I p y y 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: "1 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 applic u call fora aired inspections Co lete drawing on reverse side. Signed !1 I Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by -w Date 3 Area o -3 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE; AMOUNT REMITTED CASH RECEIVED BY CK DATE PERMIT NO. + EH 13-241REV.I/H5) EH 14-28 5' ec