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Y � y 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 SEP 13 1. . �I (Complete in Triplicate) ENVIRONMENTAL HTEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work RE lWTASIER WGIE&ation 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 3 I t e sr_X LMS_ City City Lot Size PM Owner's Name �Ks. tiLCAQ� Address A c� � f6 LAzE1 Phone i Contractor Address License No.C� --Phone ,TYPE OF WELL/PUMP: I! NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ { PUMP INSTALLATION ❑ SYSTEM REPAIR/ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL -PITS/.SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I _ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,, Specifications f'] Public Cl Other n Delta Depth of Grout Seal "-Type of Grout _ 1 1 Irrigation __!Approx. Depth l I Eastern Surface Seal Installed by � i _ Repair Work Done ❑ Type!of Pump H.P. _ State Work Done ;Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth � _ Filler Material (Below 501 _ I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ! I DESTRUCTION I ] (No septic system permitted if public sewer is II available within 200 feet./ li Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: t ;Water-table-depth- ------ - SEPTIC TANK ❑ Type/Mfg f Capacity----L— '[No. Compartments PKG. TREATMENT PLT. ❑ �� Method of Disposal 3 Distance to nearest: Well Foundation 8 Property Line iLEACHING LINE ❑ No. & Length of linoz - Total length/size FILTER BED ❑ Distance to nearest:: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number t SUMPS ❑ Di to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ II I l j y .i heieby 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 Sa1il Joaquin Local Health District. l 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 Poll g: "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 C lifo ia." Thea �! li t st call for all re ed ins A '^i pp pe ins. Complete drawing on rev r side. Signed X Title: IIA4,a eX Date: 0 Ao/ FOR DEPARTMENT USE ONLY 'Application Accepted by �r Date / Area , a I� Al or /Pit or Grout Inspection by Date Final Inspection by J Date AZI o3 _ - Additional Comments ❑ Stk 466-6781 ❑ Lodi 1�369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to:!Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 j Il ,l ~ _ EE AMOUNT DUE AMOUNT REMITTER CK DATE_RECEIVED BY - DATE_ PERMIT'NO. T +.EH 13-24 1REV.1/8 5) LA �` _ EH 14-29 ` Y{7/ p Jqc) II