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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �J Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) O J�1rc f r, t� �.eAv Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wl 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 / zl� City Lot Size T�dk a O PM ` Owner's Name 1 t'Q �/ Address /7_4_/6 � O Z Inc � Phone d Contractor Address License No. Phone TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 171 OTHER El DISTANCE TO NEAREST: S K SEWER LINES FLD. PROP. LINE FOUNDATION GRICULT L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR AREA TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Botta ❑ Manteca Dia. of Wel tion Dia. of Well Casing V ❑ Domestic/Private ❑ Gra ack ❑ Tracy Type of Casing Specifications ❑ Public cher_ '" ❑ Deltta" ` Depth of Grout Seal �'� Type of.Grout _ I I Irrigation _..Approx. Depth 1-1 Eastern - Surface Seal installed by _ Repair Work Dane" Type of Pump ►- -�-H-P: State Work Done r' I Well Destruction ❑ Well Diameter Sealing Material (top 50') ^� ---Depth ! —Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AOOITION I I DESTRUCTION PL It Cptic,system permitted if public sewer is available within 200 feet.) # Installation will serve: Residence Commercial! Other Numbed 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. ❑ t Method of Disposal L , Distance to nearest: Well Foundation Property Line LEACHING,LINE ❑ No. & Length of lines Total length/size ' FILTER BED O .-Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I 1 Depth Size Number ! r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! 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 Y rules and regulations of the San Joaquin Local Health Di§trict. ' 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 shallemploy persons subject to workman's compensa- tion laws of California." S The applic t ust c or all ui ins tions. mplete drawing on reverse side. i Signed i Title: liV� j Date: FOR DEPARTMENT USE ONLY Application Accepted by Date '' Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: _ �= i T � —:J& a�✓$..L4 L 4/`t 4- G tq LJ ... Stk 466&-6781 ❑ Lodi 369- ❑ Manteca '.823-7104' El Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 „n k A {1�1� FEE - AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO t EH1 -.21(REV. �r L�'�p,�/ J� EHH 114-2e �v�- ( "