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r APPLICATION FOR PERMIT I i1 SAN JOAQUIN LOCAL HEALTH DISTRICT NEW SrSTE01 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091 466-6781 i PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application.is heieby 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 gra City-77oOW Lot Size PM Owner's Name AC "t I�^ � AddressPhone Contractor � Address 01i-i"Aii ei icense No.-4AII Phone TYPE OF WELL/PUMP: NEW WELL ❑ . WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ T RF1E ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO5At. KD. PROP. LINE FOUNDATION AGRICULTURE WELL`• THER WELL" a PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA s TRUCTION SPECIFICATIONS ❑ Industrialj _ ❑ Open Bottom ❑ Ma Dia.of Well Excavation Dia. of Well Casing ❑ Domestic/Private Irl Gravel Packs _4 Tracy Type of Casing Specifications t �) f`1 Public ❑ Oth ` Cl Delta Depth of Grout Seal Type of Grout C10i I I lrrigatiori ,_ �.- ». _-Approx. Depth ..l,l Eastern Surface Seal Installed-by Repair Work Do Type of Pump H.P. ' State Work Done Well De ction O Well Diameter Sealin�,Moatrial p 50'1Depth Fillerw-501, f TYPE OF SEPTIGINORK: NEW INSTALLATION REPAI I DESTRUCTION I 1 INo septic system permitted if public sewer is available wit 200 fee Installation will serve: Residence Commercial�Oth ^: .` A [ 11 _LAM Number of liv'in'g—units - Number of b dr oms ��F'y`0 .- m Character of soil to a depth of 3 feet: m " Water table depth SEPTIC TANK ❑ Type/Mfg /i/ Capacity � No. Compartments PKG. TREATMENT PLT- ❑ Method ofDivsal Distance to nearest: Well , � �'Foundation a :Property Line ` LEACHING LINE No. & Length of lines Tojal length/size 6 FILTER BED 0 Distance to nearest: Well�� Foundation '�' Properfy-Line • � F sw- SEEPAGE PITS I I Depth Size Number 'r f SUMPS ❑ Distance to nearest: Well Foundation r. Property Line t `` F i a✓ 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 taws 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 Calif The applica m call f II requir d m late drawing on averse side Signed X - Title: � Data: '9 -DEPARTMENT USE ONLY Application Accepted by 00 CIA,.. �` Date 3� � Area Pit or Grout Inspection by Date 4 Final Inspection by C� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi�369-3621 ❑"Manteca 623-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO &PAOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE Q PERMIT•NO. f r EH 124 1REv.t i N 5} ;�20, O.� G �'?_/_71u Eli 14-4-26