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�>1 APPLICATION FOR,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. Job Address IV__L�12n.- QCLX_10= City 99 A Lot Size PM i - r: Owner's Name —� Address < c1 0 �' _— Phone Contractor's Name " License No. Z�ZZZa Phone i 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 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 9Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by' Repair Work bone ❑ Type of Pump H.P. F "State Work Done Well Destruction Well Diameter 'r Sealing Material (top 501 , I i Depth Filler Material (Below 50'} �I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION CE (No septic system permitted if public sewer is E in 200 feet.) available with lnstaV. Ile will serve:�Resiile`nce— Commercial_ Other + Number of Divi units: Number of bedrooms k+, Character of soil to a �3feet: � Water table depth SEPTIC TANK Capacity "- No. Compartments 71PKG. TR€ATMENT PLT. Method of Disposal i Distance to nearest: Well Foundation Property Line' LEACHING LI ElNo. & Length of lines Total ngt0size Fll_lER BED 17 Distance to nearest: Well Foundation Property Line y SEEPAGE PITS. ❑ Depth Size Number l SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ` "�14 . z ►R +� 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. 4 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 cehifies=tHe following:"I c ify that in the performance"of the"work for which this permit is issued;I shall employ persons subject to workman's compensa- tion la California." Tie a lice t ust call r all required inspections. Complete drawing on reverse side. n Signed Title:. E�JG fat c�k5w_ Date: FOR DEPARTMENT USE ONLY 7 Application Accepted by Date Area 7 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3661 ❑ Manteca 823-7104 racy 835 MA ! --,-aApplicant- Return all copies to: Environmental Health Permit/Services 1601 . Hazelton Ave. P.O. Box 2009, StkCA 95201 FEE AMOUNT DUE AMOUNT REMITTED.� SH RECEIVED BY DATE PERMIT•'NO. INFO J��y/�� i + EH 1324 MEV.10/e31 /7 ~� oU s I l-.�tp� �'/ f T''7 EH 5428 Gf