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b APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone {209} 466-6781 " PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to t.a 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. l . . ;,t< eZ City TleA Lot Size /` G PM Job Address _ - Owner's NameUA 6.2 1 Address �d Phone Phone TYPE Contractor's Name License No. e2 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El— DISTANCE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRQP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/ ❑ Gravel Pack ❑ Tracy Type of Casing Specifications p� t. ❑ Public ❑ Other. El Delta Depth of Grout Seal Type of Grout \J ❑ Irrigation __L.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done rf Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: Ni INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms r N Character of sail to a depth!of 3 feet: Water table depth SEPTIC TANK Type/Mfg Z Capacity No. Compartments s PKG. TREATMENT PLT. Method of Disposal Distance to nearest: Well +vL Foundation /f/- 7- Property Line �2 �' I LEACHING LINE No. & Length of lines 7— r Total length/size 7 - FILTER-.BED- ---- ,-i-- 'Distance to nearest: —Well------Foundation -Property-Line - -� SEEPAGE PITS ❑ Depth _ `1�0 ^� Size Number SUMPS I Distance tnearest: Well ALP v = Foundations192-77 Property Line DISPOSAL PONDS ❑ r '" n- I hereby certify that I have prepared this±application`and that thetwork w ll beAone-inn i cc nce with.San Joaquin county ordinances;statm.laws, and Z.- rules and regulations of the San Joaquin Local Health District. - — t -- Home owner or licensed agent's signature certifies the folkiwing: "I certify that in the performance,:of-the work-for which this permit is issued,; I shall not ,�employ any persgn.in such manner as to become subject to workman`s compensation lamis'of Tb forma."Contlractoei., icing or sub-contracting signature certifies the following: I certify that in ttie performance of the work foihichxhis•permit is issued, I shall employ persons subject to workman's dompensa x tion laws,of California.,'- The = �„ [ ►%� f i The applicant must call for requir'ed inspections. Complete drawing on reverse side. � F- Signed `` ` I Title: Date: L F i FOR DE PARTM ENT,USE ONLY ' , {/ 11; Application Accepted by �° " "� r Date /9 l� Area 07 ! III Date fi r1l`y Pit or Grout Inspection by Date 1 Final Inspection by t E Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ff Mantsca 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 E { _.,_FEE AMOIJNT'DUE'"- AMOUNT REMITTED — SCK RtEdEr:lD 8Y T:�::] DATE PERMIT"N0. INFD ff CASH ' + EH 13-24(REV.10/031 '7� C N jQZ — � 43 6-1 r EH 14-28 '1F' .: —