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i s{ i, c APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) e 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. 7 r r / { �/f/ . +x' �/ !.� Y �i r:r.. �i G G� if �1C,i . c:.e \. one ti AAA—— Owner's Name...-.- Address Phone Contractor L - -F k Ike e C- LM18 Address _ ` 47 -t�L� X ! License No. 4 Phone !� +► a �WaS� 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 ` pia. of Well Casing s ❑ Domestic/ Private - ---n-❑ Gravel Pack x ❑ Tracy Type of Casing Specifications l I-1 Public f_11 Other F1 Delta Depth of Grout Seal Type of Grout i'I Irrigation = -Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done •❑ Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') { Depth Filler Material !Below 50') TYPE-OF-SEPTIC,WORK:}' NEW INSTALLATION EPAIR/ADDITION i -I DESTRUCTION I I (No septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence �Comrnercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:Da e �. � Water table depth SEPTIC TANK ¢Type/Mfg t "�. C<:41C%f Ci Capacity _ :0i L No. Compartments PKG. TREATMENT PLT. ❑ ; '. Method of Dis$osal Distance to nearest: Well i�70 Foundation 1�1_15 Property Line t LEACHING LINE No. &L gth of lines c1( j 4 Total lengthlsize' FILTER BED ❑ Distanc�to nearest: Well _-_1� Foundation�� Property Line J SEEPAGE PITS it I ' Depth-! Size Number SUMPS L1''Distance to nearest: Well Foundation Property Line DISPOSAL PONDS '❑ } 1 nereny cemty that I-hgve 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. t Home owner or licensed agent's signature -certifies -the following: "I certify that in the performance rmance 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 f 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." r The applicant must call for all r quired inspections. Complete drawing on reverse side. Signed X. �"-' _ Title: -Ai-14 ,._. Date: y FOR IDEPAPTIVIENT USE ONLY Application Accepted by _ Date. - Area _ t ` Pit or Grout Inspection by � Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 "Cl Lodi -.,369-3621 • ❑ Mainteca a23-7104 W ❑ Tracyy835-6385 R Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. -Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE CK 9 + EH 13-24 (REV, I/ n 5, EH 14-26 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT -NO.