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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT La 1601 E. HAZELTON AVE., STOCKTON, CA 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 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 l Local Health District:. f� / ` ' Job Address f +� IBJ Cis(//�- C�i5 � Y& City `-4 Lot Size PM t ' J� 1 Owners Name !,A�� I _ r r£� �� Address Phone Contractor \1 f 1 L I t 1}I L_ Address CLicense No. 0 a Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _CSTAVQ1fTO_NEAREST?SEPTIC`TANK� SEWER-L-INES'"� -DISPOSALFL-D.�_'�'d"'PROP'LINE^- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Yr INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ��^9 Domestic'/Private -❑-Gravel-Pack❑-Tracy - �-�.—Type-of.Casing -- -- --- Specifications, __.� r i Public F� Other ❑ 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 t ,.Welt Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material 1 Blow 50'1 TYPE O•F SEPTIC-WORK:- .NEW-INSTALLATION I1 REPAIR/ADDITION DESTRUCTION { I (No septic system permitted if public sewer is r � available within 200 feet.) � � i Installation will serve: Res-dance "Commercial Other . Number of living units: ' r. Number of edrooms" Character of soil to a depth of 3 feet: -D O_R�• Water table depth SEPTIC TANK fa�Type/Mfg C FlIU c rF Lt Capacityil0 No. Compartments11 �--_ PKG. TREATMENT PLT. ❑ Method`of Disposal u Distance to nearest: 611 Foundation Property.Line LEACHING LINE Length of lines `to Total length/size U FILTER BED ❑ Distance'tt nearest: Well Foundation Property Line; SEEPAGE PITS I`—Depth Size `" Number SUMPS ❑ Distance to nearest:r Well,---::-- Foundation__ .�.__.____.--Property Line.' "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: "('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 California." Thea pficant st calf ail r quired inspect ions Complete drawing on verse side. Signed w Title: Date: FOR DEPARTMENT USE ONLY Application Accepted oy —Fjd " Date i Area Pi or Grout Ins ctionpe Y Date �9Q r Final Inspection by e `�" Data Additional Comments: {,�lY T:Z 4Y te .p r yi I ❑ Silk 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK 41 RECEIVED BY DATE PERMIT'NO, +.EH 14-24 TREY.1/H5) - EH 14-?8 C�