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... ,.. APPLICATION OR PERMIT .� SAN JOAQUIN:LOCAt H.EALTWDISTRICT_ 1601•E. HAZEL-T-ON AVE., STOCKTON, CA - - Teleph a (209)'466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 0 'artn .,y ,. (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. `` u Job Address FJ /� r City �/ Lot Size / PM� Owner's Name r 60,Q) Address v L �" G Phone v v V ' ' -�—�a � �2 21; { Contractorddress o' N- License Noy1sf fione9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA',CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (�\b ❑ Domestic/Private LI Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ 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 (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DEST CTIO iNo septic system permitted if public sewer is pavailable within 200 feet.) Installation will serve: Residence, Commercial_ Other a Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg G Capacity No. Compartments 2- PKG. TREATMENT PLT- ❑ Method-of Disposal Distance to nearest: Well Foundation d ` Property Line 1 LEACHING LINE ❑ No. & Length of lines . I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lini3 i SEEPAGE PITS ❑ DepthSize Number I� SUMPS EJ Distance to nearest:. Well Foundation�� Property Line ^ DISPOSAL PONDS EJ 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 i 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,I shall employ persons subject to workman's compensa- tion laws of California." The applic must call for all require inspecti ns. Complete drawing on r verse side. I Signed X Title ZAp42ga, Date: 3 _ 3— FOR —FOR DEPARTMENT USE ONLY ' s Application Accepted by Date Area,,,-- / Pit or Grout Inspection by Date Final Inspection by Date !6y Additional Comments: i Fi g P 93Y O&W k ❑ Stk 466-6781 ❑ 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 41f FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO r� �7 1/- C- f z + EH 13-24(REV.,/�51 J . U •7 3^SV �O^/v .$ EH 14-28