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7;1� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Z 1601 E. HAZEL T ON AVE:, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address rte// 8, cc Ci /�1$,� ti qty Lot Size .C/''C= PM Owner's Name "s .5 Address /f7 /✓mss vaOr � 0!?L"h-CA Phone Contractor w t ,�I ✓ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ W,LLL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM.REPAIR ID OTHER Ll 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications ❑ Public ❑ Other 3-Delta Depth of Grout Seal Type of Grout ❑ Irrigation ___Approx. Depth _ ❑ Eastern Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. State Work Done (A Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 'X Installation will serve: Residence Commercial_ Other -� Number of living units:_/_ Number of bedroom Character of soil to a depth of 3 feet: nii Water table depth ,yn/c, Yo f9 SEPTIC TANK ❑ Type/MfgCopacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. K Len th of line I 9 s7 Tptal length/size FILTER BED ❑ Distance to nearest: Well Foundation� Property Line S� SEEPAGE PITS ❑ Depth Size Number ZN1P-S ❑ 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 SanJoaquin 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}he 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 Califori1ia."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 applicaA.st call for al eq r ictions. Complete drawingonreverse side. 3 = � r Signed J _ �. _ _ D � Title: Date: — f •FOR DEPARTMENTUSE ONLY t � _ Application Accepted by Date IV 0 �� Area ` PitorGrout Inspection by r " I Date_��4 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO EH 13-24(REV.1/B 5) 47® DO III EH 1426 YYYY� �� C7D 1 r^ 1'!�/�7 .�j 3`7