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APPLICATION FOR PERMIT STAN JOAQUIN LOCAL HEALTH DISTRICT l!� " l 1601 E. HAZEL T ON AVE., STOCKTON, CA d P_ Ail� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7Y' Ge r� t (Complete in Triplicate) Application is.heleby 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 the1 Rules aT Rggulaiioonss of the San Joaquin j Local Health District. � ,tet Job Address �qka ��—�� City _W Lot Size PM I Owner'sName(�4-tom'-t7' I&A117ANtaA-, '" Address 1�9`a� ( ILAIC ItT C1'l_CZ1 Phone �a.5a .r q k Contractor �-I� I�OQ JC Atldress !4 '�au' =6 t✓F Ea Si License No. Phon p mss" i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION El ' SYSTEM REPAIR ❑ OTHER ❑ f j JJII . . DISTANCE TO NEAREST: SEPTIC TANK 9P SEWER LINES DISPOSAL FLD. PROP. LINE # ..FOUNDATION_ dG AGRICULTURE WELL OTHER WELL PITS/SUMPSJ. I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { t j ❑'Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications Ll'Public - yj� ❑ Other 171.Delta Depth of Grout Seal Type of Grout _ I-,I Irrigation }i ---Approx. Depth +I11 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump t pp{ H.P. State Work-Done Well Destruction!! ❑ Well Diameter gIlpi Sealing Material (top 501 11 Depth II Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION 1 1 -DESTRUCTIO I (No septic system permitted if public sewer is "-available within 200 feet.) Installation wilt!serve: Residence_ Comp ercial= Other I Number of living units: Number of b1ydrooms Character of soil to a depth•of-3 feet: - --- �FP - Water table depth SEPTIC TANK ❑ Type/Mfg I! Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1� Method;of Disposal 1 i Distance to nearest: Well Foundation PropertyLine s LEACHING LINE ❑ No. & Length of Imes Total length/size FILTER BED `I ❑ Distance to nearest: Well P Foundation m Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS it Ll Distance to nearest: Well Foundation Property Line f 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. I : 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, 1 shall not employ any person in such manner as to becoml subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ` certifies the following: "I certify that in the perfo ance 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 required 'ns ctic hs. r i late drawing on reverse side. Signed X , Title: Date:r/� I ! ! FOR_DEPARTMENT USE ONLY ' Application Acc 1pted by \94UN Date Area-�_ ii V f j Pit or Grout Inspection by R Date Final Inspection by Date Additional Comments: N ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 5-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O: Box 2009, Stk., CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO au CASH 2 �►- 11 + EH 3-24 IR .� J� - 1-1:39 -Y,/_ �.��, ,-Y, - EH 14-26 lj� (� /