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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 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. �y G Job Address Y Cit Se_4;4asJ Lot Size �/ PM 7 �SGirGa�f Owner's Name �_(7p/1'b �.4 ?t/l'�C' Address �r �. L "Ie<5` S-S US Phone +� Contractor i _ Phone s!, TYPE',OF WELL/PUMP: NEW WELL ❑ WELLREPLACEMENT ❑ DESTRUCTION ❑ ~ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0.' ,'. . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE y � i t FOUNDATION AGRICULTURE WELL OTHER WELL ,'PITS/SUMPS ill4TENDED USE TYPE OF WELL PROBLEM AREA '•CONSTRUCTION SPECIFICATIONS ;._w ❑ .Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy: ' Type of,Casing Specifications ' f"I Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation .--Approx. Depth i•J Eastern . Surface Seal Installed by Repair Work Done ❑ Type of,Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler�Material (Below 50') O TYPE OF6SEf}TIC.WORK: N W INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is r available within 200 feet.) r i < nstallation will serve: fiesidence Xommercial Other ,Number of living units: Number of bedrooms 1 -°-Character of soil to a depth of 3,feet: 5;%:aJ i Water table depth ,SEPTIC TANKType/Mfg L� } Capacity No. Compartments ''PKG. TREATMENT PLT. ❑ r- Imoi Method of Disposal Distance, nearest:. „ Well Found aion Property Line�t ¢ 9P_ : j<EACHING•LINE w " No. &Length of lines _19r_-cPO ;°. Total length/size FILTER B'E�]''" ""'`'``LL's' Distance to:nearest: Weil l�u�`Founda"tion / /` �f?roperty Line -4_. � SEEPAGE PITS I I Depth ZQ 0""_ Size _��/, ti _ Number r ;5`c� % = SUMPS �Q Distance to nearest: Well Foundation Property Line &2 M DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done Wit' cordance 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 applicant must call'for 11 required inspeciians. Complete drawing on reverse side'" e - 1 Signed X � ,��_ i Title: Hca �_1 Date: / I FOR DEPARTMENT USE ONLY Application Accepted by /_, !.� �t JC Date P Area ` o Pit.or Grout Inspection by Date Final Inspection by - Li Date vc ! 9 g,_ff! „ "v •. ! tom..,: .+ ,''s I4 c r, a., Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835_&385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0; Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. j }Jr INFOCASH _+. CH 13-21 tgtiV.�,i a 51 '- -. _ J .,_—___ y+i� y_._/..- -- __...=... .. ._ - ..�..._..