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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f tlp _ 1601 E. HAZEL T ON AVE., STOCKTON, CA CN y Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED risERyl�St 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District,r/W f V W 1. �,, r Job Address V rOri 4- Co rY'GE r bi [14w ' City I rR Lot Size PM Owner's Name 6�&&Pdel,'s Address 2/05/ " A, Phone .2 " Z 34 Contractor Address /O/! J. / r License Ivo Z'tI C l 7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` 'PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHERX 50g041 A(65 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES T DISPOSAL FLD. PROP. LINE �1 I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial -❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 140AIL ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications * Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ ! I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction L] Well Diameter tE Sealing Material Itop 501 Depth� L Filler Material {Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION l I (No septi em permitted if public sewer is i r av a Installation : serve: Residenncca_ Commercial_ Other within 200 feet.) Number of livirig units: Number�gf bedrooms -� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. ❑ Method of Disposal Distance t rest: Well Foundation Property Line t 0 LEACHING LI�_�L] No. & Length of lines Total lengths FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line I 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 9 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 mannto become ubie t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certifye"a - the pe or an of!hew c r which this a it is is ue I shall to per s suN ct o workman's compensa- tion laws of California." -- ( 13� 06 Thea applicant st call for d ms tns. Complete drawing-pp ��7777 PP pe p g_an reverse side. Signed X Title: �CJ �✓ G/ . pate: �� I FOR DEPARTMENT USE ONLY l Application Accepted by } Data ��+ _ Area Pit or Grout Inspection by JAMW Data Final Inspection by Date :rtcou rI�� Additional Comments: ai , Som Y�Wris.Y1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health PAY/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIVNO. +.EH1426 3-24 1 REV.i/x 51 EH 15 . Q 0