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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA L Telephone (209) 466-6781 n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {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. 1862 for well/pump and the RRull�ess and Regulations of the San Joaquin Local Health District. �7�d �/i�Pw / (27,, a a► CTc'�'-Y�y ` 97/, OXO Job Address J 1� , _ City Lot Size 260 X 300 PM Owner's Name �IilM�f/I Address Q Phone c . r Contractor �i4ddress ��• License No. �`�� Phone TYPE OF WELL/PUMP: NEW WELL Dill WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Am SEWER LINES DISPOSAL.FLD._Zlz"+- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS;— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Specifications N Domestic/Private XGravel Pack i$) Tracy + ..Type of Casing— �/ � � I ❑ Public ❑ Other: ❑"Delta- Depth of Grout Seal f='� Type of ut Q ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _-_.�— Sealing Material'Itop 501 Depth Filler Material (Below 501 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.! Installation wi Residence Commercial rt�_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fee . Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k PKG.-".TREATMENT PLT. ❑ r Method of Disposal 1 Distance to nearest: ' Well undation Property Line x 11 LEACHING LINE ❑ No. & Length of lines length/size FILTER BED ❑ Distance to nearest: Well Foundation Line SEEPAGE PITS ElDepth Size Number SUMPS ❑ Distance to nearest: l..Well , ` ' ,Foundation Property Line DISPOSAL PONDS ❑ ey I hereby certify that 1 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 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."Contractors 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." w The applicantyltst call for all require inspections. Complete drawing on rev rse side Signed Title: Dater T!' ONLY p Application Accepted by Date�A/ Area Pit or Grout Inspection by Date Final Inspection by '" Date JA Additional Comments: ❑ Stk 466-SM1 ❑ Lodi 369-3621 C1 Man ffi3 7104 ❑ Tracy 835 6385 t 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" CASH RECEIVED BY DATE PERMIT NO. ! INFO } ,+ / 1 %70991 � 1a � V-n X>�3 +"EH 13-24{qEV.7/B 55 l 0 O EH 1428 e