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f } APPLICATION FOR PERMIT SAN JOAQUi ' LOCAL HEALTH +DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT NO, -� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Application is hereby made to thejSan 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. 1862 for well/pump and the Rules and Regul/a"t�io�`n/�p of the San Joaquin Local Health District. f Job Address ([/. !r�+L-1�i�1? 7 f Subdivision Name 'sM 0/ Address Owner's Name _ Address - Phone �r. � ,Z_ Contractor's Name ;� Ql� S® s License No. Phone , TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 9' PUMP INSTALLATION ❑ SYSTEM REPAIR ! M ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a. INTENDED USE TYPE 'OF WELL PROBLEM AREA' -CONSTRUCTION PECIFI-CATIONS i Industrial ❑ OpenBottomManteca ❑ Dia. of Well Excavation �' ❑ Domestic/Private ❑ Gravel Pack Trac r- ❑ Y _,Clio. of We71'Casing ❑ Public ❑Other ❑ Delta -l �j Irrigation Type-of Casing Approx. Eastern ❑ Cathodic Protection Qepth Specifications C ❑Geophysical Depth of Grout Seal U Other Type of Grout 4 Surface Seal Installed by \ Repair Work Done ❑ Type of Pump i H.P. State Work Done V� Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth ` p - Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION {No septic tank or seepage pit permitted if public sewer is Installation will serve: R available within 200 feet.) I Residence Commercial _ Other Number of living units: 'Number of bedrooms 3 Lot size 't Sf b j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ - ' LEACHING LINE No. & Length of lines �2 (�� r Total length/size FILTER BED ❑ Distance to nearest: Well lFoundation F Property Line SEEPAGE PITS Depth Size Number 1;ff- { SUMPS Distance to nearest: WellFoundation j DISPOSAL PONDS elle r 0'.J';'/(9 Property Line " 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 issue I shall not employ any person in such manner as to become subject to workman§ compensation laws of California." Contractor's h' ing or sub-contracting signatur certifies the following. "I certify that in the performance of the work for which I this permit i ssued, 1 sha 1 employ rsons bject to workman's compensation laws of California." The appli f all re d in ction Compl etdr n r verse side. Signed X itle: + Date: Y5 62t FO EPART ENT USE ONLY Application Accepted by L� Area Stk 466-6781 Additional Comments: ..6J,f/ I �] Lodi 369-3621 Pit or Grout Inspection by � NatT4 LJ Manteca 8234104 Final Inspection by Date J54 Tracy 835-63 Applicant - Return all copies to: Environmental Health Permit/Servic`es 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. .� INFO - n EH 13-24 REV. 10/$2� � � � 10182 500 14-26 /(/�,o/tet //-- �P��ss '/r�r/� ��