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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 (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 6 �"` 0 0 ;�E 'Ty- r City f Lot Size PM Owner's Name d . iA sea,l J,a.Address � i T 5� -� '� Phone r Contractor f �" Address 0, `K License No a�/-J-1 Phone �'� TYPE OF WELL/PUMP: WELL WELL REPLACEMENT ❑ DESTRUCTION © --PUMP-INSTALLATION _ SYSTEM REPAIR-El --- -- ---OTHER-.171 x DISTANCE TO NEAREST: SEPTIC TANK D ' SEWER LINES DISPOSAL FLD I PROP. LINE 723 FOUNDATION AGRICULTURE WELL OTHER WELL-y [ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQ S � f C1Industrial XOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,Domestic/Private ❑ Gravel Pack D Tracy Type of Casing ._ Specifications -- 1-1 Public 71O�tI)er fl Delta Depth of Grout Seal pe.ofout I I Irrigation A pprox.-Depth�,_1. Eastern... Surface Seal Installed t ti t f - Repair Work Done ❑ Type of Pump C2 H.P. 3 State Work Done Well r Destruction ❑ Well E3iameter Sealing Material Itop 501 Depth--.--. ^-- .Filler Material (Below 50'1 , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [ I DESTRUCTION l 1 (No septic system permitted it public sewer is available within 200 feet \ 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. ❑ Method of,Disposal Distance to nearest: Well'- —Foundation Property.Line \t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑" Distance to nearest: Well Foundation Property Line w t SEEPAGE PITS 11 Depth Size _ _ Number SUMPS —LI—Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 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, I shall not employ any pe►son 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 mu call for all required inspections. Co-Mplete drawing on reverse side. L V- ['�- Signed X Title: _'�.� Date:` 2 1Z 7/_�5 FOR DEPARTMENT USE ONLY V R cwt Application Accepted by v , N Date� 7 ` Area t7 - . - _ t Pit or rot Inspection by Date Final Inspection by1SZ2 Date Additional Comments: ❑ Sik..466-67.81,_❑ Lodi 369-362.1 ,.❑ Manteca-,823-7104, - -❑Tracy-835-6385- — Applicant- Return all copies to: Environmental Health.*Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH �f M EH 13-24(REV.r/n5) 97;�=EH 14-28 EJ ,.V