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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JL4�} 1 r ,w A/ ittT�r (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 t 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. /V /�' Job Address � � .. City Lot Size PM /57 Owner's Name r 13hA L T1 vAddress 213-0 oFZ/� 7 +dA_Z.A1V4hone C415)$35 3" D,1E7A�-r NFO 8 Y . Contractor's Name _+-01n`: 61D � License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ e DISTANCE-TO NEAREST:. SEPTIC TANK SEWER LINES �!22 r DISPOSAL FLO Z570�PROP. LINE ..11 FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IV W ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /g, Dia. of Well Casing 6 ❑ Domestic,/Private fl(Gravel Pack ❑ Tracy Type of CasingSpecifications ❑ Public, �ldQO�w�t`��er ❑ Delta Depth of Grout Seal 11i'�I2/F� Type of Grout e JFM0 r7 _❑ Irrigation _% a Approx. Depth ❑ Eastern Surface Seal Installed by T/RAGTpIZ 1I epair Work Done ..❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Na septic system permitted if public sewer is available within 200 feet.) {(Z - ` Installation will serve: Residence_ Commercial. Other l�- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 3 SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal h 4 ter , Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines g Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ! SUMPS _❑ Distance to nearest: Well -- Foundation Property.Line DISPOSAL PONDS ❑ 1 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. I 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 no-��J employ any person in such manner as to become'subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r -1; 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 must call for all required ins ctions. Complete drawing on reverse side. Signed Title: Date.IF FOR DEPARTMENT USE ONLY Application Accepted by Date S Area I Pit or Grout Inspection by Date Final Inspection by s- Date Additional Comments: f`s ✓o 4- C/ ❑ Stk 466-6781 ❑ Lodi §W3621 ❑ Manteca 823-7104 ❑ Tracy. 835-6385 4 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE l INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH W24 IREV.10183} �--_ � �ID EH 1426 �V' 1 45