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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSOED F (Complete in Triplicate) Application is he+eby`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. ... �r Job Addressjba��a E cloo.t�c� - City � t-' l tot Size l ` PM Owner's Name Address Pt✓ '-��" Phone fup �/ e Contractor `�" � � Address r ` 7 License N_�3.4 Phone_ r5335 OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ ''� OTHER ❑ _ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE FOUNDATION AGRICULTURE_ WELL OTHER WELL' ' PITSISUMPS INTENDED USE TYPE OF WELL s PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom t ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I . w ❑ Domestic/Private'" ❑ Gravel Pack ❑ Tracy Type of Casing Specifications #('� Publicia, 11 Other ❑ Delta Depth of Grout Seal Type of Grout �r I 1 Irrigation . .Approx. Depth I i Eastern Surface Seal Installed by {. k Repair Work Done ❑ Type of Pump H.P. State Work Dane S Well Destruction ❑ Well Diameter Sealing-Material Itop 501 Depth Filler Material (Below 50'1 _ -- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I l DESTRUCTION l I INo septic system permitted if public sewer is '�a lable within 200 feet.) Installation will serve: Residence ` ' � Commercial_ Other- s yl— Number of living units: A Number f bedrooms_. __._,_._. v`F "� _ Character of soil to a depth of 3 feet: 0 water table-depth_ --11-4 vs _ SEPTIC TANK ❑ Type/Mfg 410A)IS Capacity No. Compartments PKG. TREATMENT PLT:CMethod of Disposal I t f � LineI SZ7 - - Distance to nearest: WellL�._...� Foundation` j� "Property - ' LEACHING LINE ❑ No. & Length of lines r v` G Total length/size FILTER BED" ❑ Distance to nearest:^ Well Foundation d Property Line 'r i SEEPAGE PITS I 1 Depth a5 Size �� Number SUMPS Ll Distance to nearest: Well z L� -- Foundation j�� y 'Property Line D© 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. t.. l -Home owner or licensed agent's signature certifies the following: "! certify that'ih`W6 performance of,the work for which this permit is issued, 1 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 performar ce,izf the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ti ' The applicant I�st call for all requir d � coons. Complete drawing on verse side. s Signed X(,� ��'� Title: � 4- � --- Dater ,I -- FO DEP RTMENT US ONLY Application Accepted by � �� Date ✓ Area / r.1`.�Lf Date �� Pi or Grout Inspection by `` at Final Inspection b f�- Additional Comments: ©/� /O - �� 1A_ �c s 111-t A.I ❑ Stk 466-6781 ❑ Lodi 369-3621 C7 Manteca 823-7104 ❑ Tracy 835-6385 7i a P,a-r>+r. 0- S Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. INFO a EH 3 24 k f"EH14-2giFEV.riK51 � QR `��