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APPLICATION FOR PERMIT' c SAN JOAQUIN LOCAL HEALTH DISTRICT 0itAl ` 1601 E. HAZEL T ON AVE., STOCKTON, CA p AY 1r�ED Telephone 1209) 466-6781 RF.G 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 cleaq, (f&ion is- made in compliance with San Joaquin County Ordinance No. ules 549 for sewage or No. 1862 for well/pump and the Ra � Sin Joaquin Local Q Job Address: / 't11` City Lot Size PM V. Vi Owner's Name / , Address .Q,377 8 &44, - 1 f Q L��C� Phone Contractor 5 Address n52S AXir a.�eGlt�.. !'419�cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �D , SEWER LINES DISPOSAL FLD.s7V"t PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL fvO z PITS/SUMPS INTEN1EDmUSE TYPE'OF-WELL PROBLEM AREA ~-CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation A2�`_ __ Dia. of Well Casing )Q Domestic/Private X Gravel Pack 10 Tracy Type of Casing f�f�C Specifications t 1`1 Public I1 Other ❑ Delta Depth of Grout Seal /da Type of rout I I Irrigation - --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ F^� Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/ADDITION I I DESTRUCTION I 1 INo 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. R Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 .Depth Size Number SUMPS i_1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ~-- 1 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 Di?;trict. 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 ust call for all required inspections. omplate drawing on re arse side.. Signed X Title: �O Date: "� �'Zo 'If FOR DEPARTMENT USE ONLY r` f Application Accepted by t Date Q Area D e. Pito ro Inspectio 1 ^ a*d/ Final Inspection by Date A Additional Comments: ` -`-7 / p��P& ! OL l/�2 U 60/.'7�I d I Y�SC'P C /'1 �{ c G -4? �� ❑ Stk 466-6781 ❑ Lodi 369 ❑ Men ca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a . INFO AMOUNT DUE AMQ�OUNT REMITTED t�AS}}H( RECEIVED BY r D4T,E ¢ PEE(RMIT NrO.. FEE+.EH 13-24IREV.liµ5J Q 7 O `�-- `'[ � v ll� t 1 r � l�f rL�4 r,- EH 14-26 - C(