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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 60iCompiete in Triplicate) af�7— 2-Go, a-6 App(cation is hereby made to the San Joaquin Local ealth District for a permit to construct and/or install the work herein described. This application is Y 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. Jab Address City > Lot Size PM Owner's Name } r L // ` Address /o Phone !a C t`3d,9b _ Contractor JO /�. Address z r Phone License No. S ;(F TYPE OF WELL/PUMP: NEW WELL ❑ 4WELLREPLACE NT ❑ DESTRUCTIONS PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �. Dia. of Well Casing ! 1-1Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal I ! Irrigation A Type of Grout _ pprox. Depth I I Eastern Surface Seal Installed by p Repair Work Done ❑ Type of Pump H.P.' State Work Done_ d Well Destruction Well Diameter Sealing Material {top 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW-INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence Commercial= Other ti } 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. ❑ t{f p Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size ' FILTER BED ❑, Distance to nearest: Well Foundation � Properly Line SEEPAGE PITS I I Depth Size Number SUMPS Lf Distance to nearest: Well Foundation I Property Line DISPOSAL PONDS ❑ j j� 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 1 rules and regulations of the San Joaquin Local Health District. Home owner or licensed an s signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in s h ner as become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: 'I ce tha!<iAthe pert ante of the work for which this permit is issued, I shall employ tion laws of Califomi p V Persons subject to workman's compensa, The applicant mus al o al re ui spt3ctions. Complete drawing on reverse si e Signed X Title: Date: FOR DEPARTMENT USE NLY ' Application Accepted by 49, Date Pit or Grout Inspection by Date Fina( Inspection by ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi •369-3621 EJ 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 AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.fin 5i � EH 14-28