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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .,2 1 -?36 0/64•uOe2 City P)AAJTccA Lot Size PM Owner's Name Shy t�� d4�r 2. /C ' 3 b ©1cgoerz Phone ,A 3 r 4, 2871 ♦ f 2 p Contractor CAaa I Address /�~0 �� License No. yJ�I phone 023'6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r„ J. FOUNDATION AGRICULTURE WELL .c]THER WELL 'PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM—AREA CONSTRUCTION SPECIFICATIONS i ❑,Industrial ❑ Open BottomL+s Manteca Dia. of Well Excavation Dia- of Well Casing ❑Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout El Irrigation --Approx. Depth EJ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material 1Bel w 501 'i. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 9 DESTRUCTION ❑ (No septic system permitted if public sewer'is L available within 200 feet.) � ! Installation will serve: Residence 0 Commercial' Other 1VurStbe�of"rJing-units: '�"—'Number of rooms ' Character of soil to a depthof3 feet: -- �N -- Water table depth i SEPTIC TANK ffthType/Mfg f Capacity JZR0 64C Noi Compartments PKG. TREATMENT PLT. ❑ t ,tl I , Method of Disposal r Distance to nearest-.4 Well Foundation Property Line LEACHING LINE No. & Length of lines Tota �_ 9 J ., llength/size , FILTER BED ❑ Distance to nearest: well 1_,_df._ Foundation`�j-� Property Line ��V v SEEPAGE PITS ❑ Depth Size Number 1 _ SUMPS ❑ Distance to nearest: Well Foundation ;Property Line DISPOSAL PONDS ❑ 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 mariner 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 subjecfto.Workman's compensa- tion laws of California." The applicant mu/ call for all required i_ns tions. Complete drawing on reverse side. Signed X !(+ � `.'vP""`) Title: [,Wa CA� Date: FOR DEPARTMENT USE ONLY f f Application Accepted by Date �r/ l� Area 4 r i (� p,6 Pit or Grout Inspection by Date Final Inspection by_ �� /L.hG!^--- Ole �/0 `, 4 z' rff P Additional Comments: ! 3 ❑ Stk 466-6781 j ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy- 835-6385•�-- - -u 3 t Applicant - urn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.. CA 95201FEE p `INFO AMOUNT.-DUE AMOUNT REMITTED• CASH RECEIVED 8Y"-" DATE" PERNI4Y ND. + EH 13-24 iREV.i i a 5; �7� 1 I�� f� yj �� x EH 1428 (f 1 iJ VVV