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:'. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �f 1601 E. HAZELTON AVE., STOCKTON, CA J � 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 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. Job Address X17' •,, . 264434a41-4;kCity Lot Size PM Owner's Name Address [� /��►�1.tL-ga.l y Phone Contractor's Name /"T'rT-'�d ��„Q,J License No. �.�U� _ _ Phone ex TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER l DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ile Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other �� M Delta Depth of Grout Seal Type of Grout l� ❑ Irrigation Approxi Dep ❑ Eastern Surface Seal Installed by h y Repair Work pane ❑ Type of Pump H.P. 4ate Work Qone Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �h available within;200 feet.) Installation will serve: Residence!! Commercial_ Other s Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth s-2 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments' PKG. TREATMENT PLT. ❑ �I 1 ., .Method of Disposal- Distance isposalDistance to nearest: Well Foundation .a Property Line "' LEACHING LINE ❑ No. & Leh gth of lines Total length/size FILTER BED ❑ Distance to nearest: yWell1Foundation , Property Line J. SEEPAGE PITS ❑ Depth II Size 'Number SUMPS ❑ Distance to nearest: Well Foundation 6 Property Line— DISPOSAL PONDS ❑ f 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." I. P The applicant must call f II required inspections. Complete drawing on r -rse side. _J Signed X ��> � Title: G�->��^��` Date: T f� I� ,..,,, FOR DEP RTMENT USE ONLY Appiication Accepted by Z_1/ f � .y Date Area l� Pit or Grout Inspection by NJ 1 A ___ Date 00, Final Inspection by AAAlf— bate 1 Additional Comments: I` ❑ 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. Bax 2009, Stk., CA 95201 i FEE AMOUNT DUE i AMOUNT REMITTED I RECEIVED BY DATE PERMIT`NO. INFO CASH li + EH114,26 24(REV.1a/x1) EH . �� 31�-aY C� 9-k