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APPLICATION FOR PERMIT a�. m SAN JOAQUIN LOCAL HEALTH DISTRICT ; .' 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 171-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. r. Job Address �59 9� 4 City+ L' Lot Size Q PM Owner Name - G �. Ty��I Address D r��}�( �-t _ �rP �,�,� LL STI Ga Phone 1� Contractor , Address ��roX License No. Phone TYPE OF WELL/PUMP: NEW WELL?< WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �. SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION ` AGRICULTURE WELL;�� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION§ r r ❑ Industrial 7COp.n Bottom ❑ Manteca19 Dia. of Well Excavation 1Z- Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing sk t'r f Specifications I Of eiC F-1 Public ❑ Other ❑ Delta Depth of Grout Seal 58 jType of Grout �h^ln ❑ Irrigation 2�&Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ftop 501 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 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: E Water table depth SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to.nearest: Well Foundation Property Line r i LEACHING LINE ❑ 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 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 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 of California." The applicant call for all re wired inspections. Complete drawing on reverse side. _ i Signed� - Title: _ Date: ,',7 _24--07 FOR DEPARTMENT USE ONLY s Application Accepted by Date Z Area Pit or Grout Inspection ti r Date � Final Inspection by AZZ� D,t.A1aA7 a Additional Comments: _ltf✓ Lrr�-- 1 pg s-0 �- - -+iY►� l�Gc�l.�tyt l i`L ❑ 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 , INFO AMOUNT DUE AMOUNT REMITTED_ - RECEIVED BY DATE PERMIV NO. CH 112;+ EH 1428(REV-I/s 57 —7 O C9 tole C-41'