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APPLICATION FOR PERMIT 2 SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 Q PERMIT EXPIRES 1 YEAR FROM DATE ISSUED No\P (Complete in Triplicate) 10-41 Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describe . 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 &Q:t s© ,&w-x,y 4V4 f CityZ264L Lot Size PM Owner's Name !✓a�j ��s� �(�� Address stI7 `7.> Au5 Phone &i Contractor aom Address License No. Phone 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 (CULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA __ SPECIFICATIONS El Industrial ❑ Open Bottom ElM�a%esa—'----Dia. of Well Excav _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack p...---"'f7 Tracy Type of Casing S ecifications FI Public ❑,¢cher ❑ Delta Depth of Grout Seal Type o Srel _ I I Irrigation - "' _.Approx. Depth I I Eastern Surface Seal Installed by Reppk-W&k Done ❑ Type of Pump H.P. State Work Done_ t Well Destruction ❑ Well Diameter Sealing Material (top 50') 000??} Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l 1 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Q Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation IProperty Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ 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 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 applicant must call for all re wired inspections. Complete drawing on reverse side. / Signe Title: &r- Date: FOAjaEPARTIVIENT USE ONLY Application Accepted by L Date �J Area l Pit or Grout Inspection by J,3 !2Date Final Inspection by Date GJ Additional Comments: �� /_ ��G:/� 1� � o,� pel U"�G U� � � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O 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 AS RECEIVED BY i DATE PERMIT'NO. + EH1 -24(REV.tix5) C90 SLS C3 C EH 144-28 C1 lll.X O V 1p