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� a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) j 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 thp,San Joaquin Local Health District. Job Address 55Y Z'e C 1 `L r pl^Ll City �� E t Lot Size PM Owner's Name L Address �`� l "�` � /� /�1 /`Vl1 f! Zl ii+('Yf J�hone Contractor .0 Ltlt. Address � `> k-t _ Cense No. ��f� Phonef�`> TYPE OF WELL/PUMP: NEW WELL EPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SY.S.L_RFPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. C� PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL 76' PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ZV Dia. of Well Casing X Domestic/Private JV Gravel Pack X Tracy Type of Casing PV(- Specifications / M Public n Other ❑ Delta Depth of Grout Seal Cr Type of Grout f Ttif f I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed byEi�1 _ 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 I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is C� 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 Distance to nearest: Well Foundation Property Line C� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 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•"ttrat the-WOTk-VVM' t3 done"rit c r -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,1 shall employ persons subject to workman's compensa- tion laws of California." The appli ust call for all requires inspections. Com ete drawingionerse dsidSignedX L {c-qz `// tom' '�� Title: .�-,.�-< c / Date: r OR DEPANT USE ONLYf Application Accepted by Q Daterea Pit or Grout Inspection by Date Final In action by Additional Comments: �2 01 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO H +.EH 13-24(REV.i i x e) ' EH/4-28 O- J , 8 -��vnp r F�ICS d �t,,al o,t r✓k �e. .r�e f s l Ci" ✓rce