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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. � 1 � Job Address 192 r) City 0 Lot Size PM Owner's Name Flc ii Phone • 'C 2`scZ '��` s `v Aa No. �� a Phone "z•3' Contractor 1 % 011 CAUL ke•Address, F TYPE OF WELL/PUMP: . .. ,_._NEW„WELL_❑._-WELL REPLACEMENT O DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - .z OTHER ❑ 4j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP.OSAL.FLD. 7 PRop. LINE FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS !_•f x INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS1 I-] Industrial ID Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well.,Casin9/• ' El Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Spec*ficatio}s ' 71 Public f! Other C Delta Depth of Grout Seal Type,of.Grout's I I Irrigation ApproAepth . I I Eastern Surface Seal Installed by 1 � �)` - s 4 i Repair Work Done ❑ Type of Pump,. H.P. ,State Work Done Well Destruction El Well Diameter Sealing Material (top 50') €fit Depth }� Filler Material (Below I TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION Hr DESTRUCTION I I INo-septic syst6m,pe6itted if public sewer•is I ' available within"200"feet))-- 1 installation will serve: Residence_ Commercial_ Other _ _ ��` i Number of living units: Number of bedrooms -1 e Character of soil to a depth of 3 feet: .� A1>kL Water table depth £` a SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ,` d PKG. TREATMENT P.LT..(� � .,x�� j Method of Dis posal\,� � l g} Distance�to nearest: Well Foundation Property Line- , Total le ` i j K n th/sizes LEAdIING LINE ❑ No. & Length of lines -- .- 'g FILTER BED ❑ Distance to nearest: Well J Foundation Property Line SEEPAGE PITS 11 D 4th I Size Number t SUMPS t< Distance to nearest: Well T Foundation i Property Line DISPOSAL PONDS ❑ i 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'Joaquiri Local Health District. r 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, 1 shall not empioy8ny person in such manner as to become ubject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the p X ante of the-workJor-which,this permit.is.issued„[.shall employ persons subject to workman's campensa tion laws of California.” 1 The applicant munt rsw for all rep •'d inspecti s. Complete drawing on reverse side. ` ^�• Signed Title: "~— Date: Gg. gg � 21 , FOR DEPARTMENT USE ONLY ' +' Application Accepted by - Date Area Pit or Grouthnspection by Date Final Inspection by ate � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant„Return all..copies-to:_Enviro`rimental_Health'Permit/,Services 1603-E.-,Hazelton-Ave,P-.0-Box-2009;Stk,CA-955201 -- � I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH / o f��j + EH 13-24{REV,i/RS) 70 1 /�� ¢` �.� C_.y(�-� (J t��T V / .-.1' . EH 14-25 6