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APPI::°ECATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i " r 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. f Job Address p�� !y_r>! RC1 City C)e Lot Size PM vt Dwrier's"Name V 6JP&k,,e9~r4F_S 'Address - - - - - — Phone ContractorILT y s O/r Address 400A /,3L V t' 01"I �vf /License No. �1_�89I Phone TYPE OF WELL/PUMP: � NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . <,y PUMP INSTALLATION ❑ : SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WECI-7 PITS/SUMPSt INTENDED USE .11:TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing , 1-1 Domestic/Private- ''❑ Gravel Pack C3 Tracy Type of Casing Specifications I'1 Public F`1 Other F1 Delta Depth of Grout Seal Type of Grout__. I I Irrigation A.- Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done•„ ❑ hype of Pump H.P. W State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is f available within 200 feet-) Installation will serve: Residence— Commercial____ Other del Z41 /ersea�G Number of living units: Number of bedrooms s, Character of soil to a dep h of 3 feet: "`CSE �� + ` �l. Water,table depth ? SEPTIC TANK Type/Mfg Pre+ e,r99T Capacity ��Q a No`. Compartments ' PKG. TREATMENT PET. ❑i t Meth6d of Disposal. t Distance to nearest: Well l�Q •Foundation Property Line., 1 LEACHING LINE iZIF No. & Length of lines 1 Ot7 Total length/size PQ A FILTER BED ❑i Distance to nearest: Well I J Foundation Property Line .4`O 1 SEEPAGE PITS I I Depth Size Number SUMPS Llh Distance to nearest: 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 Diltrict. y 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 far which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." s The applicant mus all for all required inspections. Complete drawing on 'ever a side. I { Signed X _ �� Title: Date: i DEPARTMENT USE ONLY Application Accepted by �Gt .. — Data " t Area Pit or Grout Inspection by Date Final Inspection by 4 9 Oat Additional Comments: C❑ Stk 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 RECEIVED BY DATE PERMIT'NO. EH 24(REV.i/n 51 4- EH 14-26 I� 0 ID [ L�� V— 1 9 0---a SII: