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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL"HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f -Telephone (209) 46 6.6781 v PERMIT EXPIRES 1'YEAR FROM DATE ISSUED' /VZ La 4 (Complete In Triplicate) y.. -• � s.. i ,SFr. . ,.7 - -. 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. U.Y. Job Address V; `j �ry 5h G111 J City Lot Size " PM Owner's Name Address 1�9� 7V, lI J� �I �� =�L'� Phoria Contractor Addr�ass µ c , License No. I Phone _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI0101 SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINESDISPOSAL FLD. f PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationop l Dia. of Well Casing Xh Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing E Specifications Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth q Eastern Surface Seal Installed by k Repair Work Done ❑ Type of Pump S g a H.P. � f Ey.do � State Work Done i 'c+ /� j Well Destruction ❑ Well Diameter �, Sealing Material {top 50') !I Depth Filler Material (Below 50') # n A TYPE OF SEPTIC WORK: NEW 1NSTALLATIOIV ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is I } available within 200 feet.) Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 11 Water table depth Capacity—SEPTIC TANK ❑ Type/Mfg i � p tY No. Compartments y PKG. TREATMENT PLT. El Method of Disposal " ( Distance to nearest Well Foundation Property Line { A s. . LEACHING LINE ❑ No. & Length of lines Total length/size F i FILTER BED ❑ Distance to nearest: Well Foundation Property Llne SEEPAGE PITS . ❑ Depth :Size Number . SUMPS ❑ Distance to nearest! Well Foundation Property Line DISPOSAL PONDS 7) ( 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: "1 certify th`atin the perFf6rmance oft ele world for which this permit is issued;-l shall not employ any person in such manner as to become subject to workman's compensation laws of California.,3ContrI ctoe-s hiring or sub-contracting signature certifies the fallowing: ;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."' � � � 1 The applican m at call for"all�req it d in tons. Com late drawing on-reverse side., h X Signed [ 7� Title: j. t. Date:_ FOR DEPARTMENT USE ONLY . I 4 Application Accepted by _ tel `' Area Date Pit or-Grout Ins ; y f L,% r'j Pectio Date �Final Inspection by Date � I / i Additional Comments. /9 { ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- 04 ❑ Tracy 6385 A - 101 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` Applicant- Return all copies to: Environmental Health Permit/Services6 .— .�.. A INFO AMOUNT DUE AMOUNT REMITTED CASH �--"�-RECEIVED BY DATE PERMIT N0. I + EH 13-24.IREV.i/e sl 1 EH 14-26 i r w f