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E ' APPLICATION FOR PERMIT ° SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDy}4 (Complete in Triplicate) /'1?�" - 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. (�'+ %%��t ,,// y� f �/ TS l` Cit S /Lf Lot Size _ D /1 / PM '� Job Address 1 - Y �/ d�ZPh.n. Owner'sName ISAJLAe-S SO/� 4/J�RE Address 6 y�� 3.� r.y z-%y S T �' 77 -2 }"—Contractor �`� /l' Address License No. Phone7;�z / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ nteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f7 Public (=l Other n Delta Depth of Grout Seal Type of Grout— x, I I Irrigation _".Approx, Depth l I Eastern 'face Seal Installed by- Repair y_Repair Work Done ❑ Type of Pump H,P. State Work Done _ t r Well Destruction. ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR/ADDITION I DESTRUCTION'y( (No septic syste"m'permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial�: Other Number of living units: Number of bedrooms R Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must-C r all r uired ispections. Complete drawing on reverse side. Signed Title: l.t�h!v Date: t FOR DEPARTMENT USE ONLY t Application Accepted by r -� Date �- Area Pit or Grout Inspectio y. Date C Final Inspection by Date Additional Comments: �( ❑ Stk 466-6781 11 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~ INFO AMOUNT DUE AMOUNT`REMITTED CK RECEIVED BY DATE PERMIT"NO. +.EH 13-24(REV.t i H 5] 3�i C7 3500 S U EH 14-2e —