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A# APPLICATION.FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT S 1601 E. HAZELTON AVE., STOCKTON, CA Now ��r7t ►,&(L Telephone {209) 466-67$1 PERMIT EXPIRES 1YYEAR FROM .DATEjISSUED N� lL_' 1` .}» .;" (Complete In Triplicate) Application is heieb made to the San Joaquin Local Health District for } pp y q 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. L Job Address � � `�R n A�7Ltli� , / /� City �lll. n.s!1 Lot Size t ry, PM Owner's Name JbS S J414 " CA.Aid�dress �VD 9d phone - Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI IFICATIONS ❑ Industrial' ❑ Open Bottom ❑ Manteca D' elf Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public "❑ Other' - alta Depth of Grout Seal" }Type of Grout ❑ Irrigation �4ppr epth ❑ Eastern Surface.Seal-installed By - Repair Work Done ❑ of Pump H.P. State Work Done._ Well Destructio 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 (a " 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: Water table depth SEPTIC TANK ❑ Type/Mfg "Capacity f No. Compartments PKG. TREATMENT PLT. ❑ .; Method,of Disposal Distance to nearest: Well Foundation Property.Line.. i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number I SUMPS ^❑�-Distance to nearest:""" Well - Foundation - -Property L-ihe"' 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."Contractors hiring or sub-contracting signature certifies the following:"1 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 must call for all quire inspectio . Complete drawing on reverse side. 1 Signed Title: Date: F ARTMENT USE ONLY Application Accepted by j4A,�, t, ate ' Brea Pit or Grout lnspectio y Date Final Inspection by Date Additional Comments 5 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑.Manta -7104 0-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 AMOUNT�REMITTED CK RECEIVED BY. DATE PERMITNO. + H 1 7/H V V uV ' �J'/ / ^� E 4-28.REv. 51 '-l�� s�� f� l +� ! !/J_(� O /" 1✓`�/ EH 14-28. J '