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i APPLICATION FOR PERMIT CO J SAN JOAQUIN LOCAL HEALTH DISTRICT LA- 1601 E. HAZELTON AVE., STOCKTON, CA ` A Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED [ (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 t 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 V250 B�� 1Z-�ZC /ZZ=- , City —5 1�t''A--) Lot Size PM Owner's Name Tri E'�� Address .45e5_t -?e Phone l Contractor �i�l o Address d �&X, i Jicense No.Z Y-3-.54--f-Phone 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ -DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ IJISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i ('1 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout , I i Irrigation ---Approx. Depth l I 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 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is 1. * . available within 200 feet.i Installation will serve: Residence t Commercial_ Other Number of living units: Number of bedrooms _. Character of soil to a depth of 3 feet: Water table depth 6,[D SEPTIC TANK ❑ Type/Mfg Capacity /Z©[] No. Compartments z- PKG. TREATMENT PLT. ❑ �. f � z Method of Disposal Distance to nearest: Well Z.45�0 Foundation L Property Line d© LEACHING LINE fX No. &'Length dunes Z y 5 Total length/size r k FILTER BED ❑ Distance to nearest: Well Foundation ? Property Line SEEPAGE PITS /I� Depth Size $ Number 2_ SUMPS Cl Distance to nearest: Well F.oundation FFCZ Property Line -_ DISPOSAL PONDS ❑ I hereby certify that t 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:,"l 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 required inspections. Complete drawing on reverse side. E, Signed X � Title: Date: — —e3;r— FOR DEPARTMENT USE ONLY Application Accepted by Date Area . Pi or Grout Inspection by Date Final Inspection by Z4a_--t Dat _/3 Add'Tonal Comments: ❑�Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 F # - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 4 .r INFO AMOUNT DUE AMOUNT REMI7TE0 ASH RECEIVED BY DATE PERMIT'NO. r EH 13-24(REV.1iH51 [7 / EH 14-26 rJ/V Z1 4 <.