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l r�0 APPLICATION FOR PERMITS SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZEL i ON AVE., STOCKTON, CA ` Telephone (209) 466-6761 t IJAY PERMIT EXPIRES T YEAR FROM DATE ISSUED ,"VV,, (Complete in Triplicate) F F.f, ,�' .. j, ISS-�t�l, L T11 i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described 1%is.application is f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump art the R las and R ulatio f ttre San Paquin Local Health District. ''f�3�3 �f :Q .41Vy -14�� 1.,, ,� �{� a�y � N . a "3 f-� ✓ Job Address Z_q tCJr ��- � ., "d W city + Lot Size PM Owner's Name — 'e+ �/�t C��'"• ._— Address _1 5�7_ID '�5— �r ��Q►l y Phone : sp 7q;0 Contractor G4012Jr P)`_ _Address 3 O F A'c / �1 �- License No. Phone f TYPE OF WELL/PUMP: NEW WELL WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTAL TION Q SYSTEM REPAIR ❑ THEP ❑ 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 SPECIFICA 12 ❑ Industrial ❑ pen Bottom ElManteca Dia- of Well Excavatio Dia. of Well Casing Domestic/Private Gravel Pack. 'Tracy ,,._,,,,.,,,.T,ype of Casing Specifications ❑ Public t�❑.,,OU"1er El Delta Depth of Grout Seal Type of Grout " F-1Irrigation 11��Af pprox. Depth El Eastern Surface Seal Installed by -A Repair Work Done ❑ Type of Pump H.P. State Work Done �1 t W Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below-501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_',.Commercial— Other 3 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 I LEACHING LINE LJ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line t 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, 1 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applican st all foSod r r inspections. Complete drawing on r*r�- Signed X Title: Date: I ' FADR DEPARTMENT USE ONLY I _ Application Accepted by Date �5 Area Pit or Grout Inspection by Date ��' Final Inspection by Date Additional Comments: ❑ Stk 466-67810 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 RECEIVED BY DATE PERMIT''NO. + EH 1 -241REV.t/e5) EH 144-29 c