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r V - APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT b� - �_ Ac 1601 E. HAZELTON AVE., STOCKTON, CA C '�-�\r ' Telephone (209) 466-6781 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 Rules and Regulations of the San Joaquin ' Local Health District. Job Address —L{E K City Lot Size Address zd L,L/ !tel _ Phone Owner's Name r- 1. Cld License No. �- Phone Contractor Address TYPE OF WELL/PUMP:._ .,,,.NEW WELL-❑ , WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION L SY TEM$ REPAIR ❑ B- + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AL FLD. PROP. LINE FOUNDATION .AGRICULTURE WEL OTHER WELL PIT51Sl1MPS INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom D eca Dia. of Well Excavation Dia. of Well Casing ❑ OomesticlPrivate ❑ Gravel Pac ❑ Tracy Type of Casing " >" Specifications y f'l Public Cl n Delta Depth of Grout Seal i Type of:Grout _. Q t i j I Irtidation --Approx. Depth I I Eastern Surface Seal Installed by i Repair Work e ❑ Type of Pump H.P. State Work'Done�- - - W Well truction ❑ Well Diameter Sealing Material Itop 50'1 v Depth L Filler Material 19elow 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION I I DESTRUCTION V1INo septic system permitted if public sewer is available within 200 feet.I Installation will serve:" Residence Cornmercial Other. Number of living units: Number of bedrooms _ 3 Character of soil to a depth of 3 feet: Water table depth f a SEPTIC TANK ❑ Type/Mfg Capacity No'.'Compartments r Method of Disposal r PKG. TREATMENT PLT- ❑ #,. I Distance to nearest: Well Foundation Property Line LEACHING LINE r ❑ No. & Length of lines' } .Total length/size � FILTER'BED ❑ Distance to nearest: Well Foundation Property!Line J.. l SEEPAGE PITS y I I Depth Size Number. SUMPS Ll Distance to nearest: Well Foundation .- Property Line DISPOSAL PONDS ❑- I 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 thatrin 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 applicant must call for all re ired inspections. Complate drawing on reverse si e. Signed X Y Title: Date: ' r r , FOR DEPARTMENT USE ONLY _ 4 Application Accepted by z - - - --Date Pit or Grout Inspection by Date .Final Inspection by Date J Additional Comments: M 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 C] Manteca 823-7104 `\❑ Tracy 835-6385 9` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazajton Ave., P.O. Box 2009, Stk., CA 95201 . err IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'NO. f + EH 13-24 IREV.I/H 51 TZVI/ _ EH 14-26 tJ J