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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) �.y3'.yZJ .•. 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. "" r. �'` t o �.. Job Address - d tO / S 0 / / r � City dG�Z".Lot Size 0 — 1� PM. Owner's Name 34V9.! �(�d7.11TV r"�rAddress, d C� / -- d 5C� .:` Phone Contractor ---- -- Address License.No.- I Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK € SEWER LINES, - DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a a INTENDED USE --*TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy I Type of Casing Specifications ❑ Public ❑ Other ❑ Deka ( ^° ^'"'De"th of Grout Seal r k P Type of Grout ❑ Irrigation _Approxi Depth ❑ Eastern Surface Seal Installed by c t Repair Work Done ❑j Type of Pump H+P' State Work Done Well Destruction ❑j Well Diameter '.. ealing Material (too-50') t F f )# Depth Filler Material (Below 50') A-- i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) 'installation will serve:. Residence J✓ Commercial_ Other Number of living units:--I— Number of bedrooms := F Character of soil to a depth of 3 feet:# Water table depth SEPTIC TANK ❑ Type/Mfg1. Capacity L— " No. Compartments PKG. TREATMENT PLT. ❑ Method.of Disposal Distance to nearest: Well Foundation' Property Line LEACHING LINE O No. & Length of lines Total length/size t,.. FILTER BED 4 ElDistance to nearest: Well # Foundation t Property Line x SEEPAGE PITS ❑ Depth ..l Size Number i E SUMPS, ❑ . Distance.to nearest:- Well -Foundation ;Property Line x DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work W il(be done in accordance with San Joaquin county ordinances;state laws, and rules and regulations of the San Joaquin Local Health District. . j. r i. 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 must call for all required inspections. Complete drawing on reverse side- / l �!: Signed Date: ` FOR DEPARTMENT USE ONLY - ! p Application Accepted bArea y Q Dat e Pit or Grout Inspection+by . Y Daae'' Final Inspection by ✓J Date p Ad itional Comments: 1 ! ' 466 6781 ❑ Lodi 3621 ❑ Mghteca 823-7104 ❑ Tracy 835-6385 (/ Applicantplil�cant_R Return all gie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAS 201 D VI O Ay E FEE AMOUNT OUE INFO .-..AMOUNT,REMIITED� _-ASRECEIVED BY —DATE ___DATE PERMI7;N_0.� + EH 1324(REV.1/8 5) EH 1426