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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 19 mnEt";'201E"" 1601 E. HAZE.T ON AVE., STOCKTON, CA ' Telephone {209} 466-6781 MAR � � �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worlLlaIN luWUWlication 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 /o-a C 1 V ,t_6_r`-ot __ - City Lot Size PM � /� r FA-1!CS Owner's Name7q',� t ,, AddressiYrG �-tti>Za Phone _ Contractor),-W Address�� cZs iii �3*Y –_License No.�39&Z Phone- � � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR �X OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIVE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing Nomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('l Public 1-1 Other CI Delta Depth of Grout Seal Type of Grout_ I I Irrigation --Approx. Depth l I Eastern r Surface Seal Installed by - Repair Work Done X, Type of Pump H.P. /-� _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is N available within 200 feet.) Installation will serve: Residence— Commercial_v Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No:-Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthisize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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." The applica st�allfoRaW required inspections. Complete drawing on reverse side. Signed X if Title: Date- ` 7 FOR DEPARTMENT USE ONLY Application Accepted by Date Q0 Area ! Pit or Grout Inspection by Data Final Inspection by Date `l0 Additional Comments: ❑ 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. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED rK CASH RECEIVED BY DATE PERMITNO- + EH 13-24 IREV- / 51 EH 14-26 YJ o 90--S e'{