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f f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT „1601 E. HAZE.—A ON AVE., STOCKTON, CA Telephone (209) 466-6781 t j 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 • 2irk/ ' � k "' City��CrV Lot Size Xe9 fi_c(�JrS PM .. ` 't Owner's Name 0 � � R//� Address ��,r�.O3 / ) 1AA JS_ �� Phone E Contractor ,� ` ressi7�,!�C`2�� D/ICa License IVa. y��D`��J—/_Phone TYPE OF WELL/PUMP: ' 1l NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Eel SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK_,<) SEWER LINES ZJ(J+C7� DISPOSAL FLD.�gROP. LINE ZLO� - FOUNDATION jJ A/ AGRICULTURE WELL _/20_J__C.OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ;pomesticlPrivate :Ek/Gravel Pack C1Tracy Type of Casin � �� Specifications ❑ Public ❑ Other• ❑ Delta Depth of Grout Seal _� Type of Grout 7L ! ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by �V Repair Work Done ❑ Type of Pump c rltSZ2? H.P. State Work Done Well Destruction ❑ Well Diameer �.._ Sealing Material (top 50') i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I. available within 200 feet.) i Installation will serve: Residence Commercial_ Other 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. ❑ h Method of Disposal Distance to nearest: . Well Foundation Property Line I LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line { SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: .. Well Foundation Property Line 1 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, k shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 Californ' ' The applicant m6s all for all required inspections. Complete dr g on reverse side. Signed Title: o/J -& � Date: 6 i OR DEPARTMENT USE ONLY Application Accepted by Date Area _ v Pit or Grout Inspection by Date Final Inspection by Date Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 4104 Cl Tracy 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT-DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMIT`NO. ` INFO + EH 13-24(REV.i/a5) r !/�.( 111V,!77 - s- EH 14.26 L/