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Ule I� APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,-STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t '(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 � L , � �' � _r % [try `� Lot Size PM Owner's Name 19-To"Q Phone 7/ I Contractor Address �License No. Phone TYPE OF WELL/PUMP: i1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C1 SYSTEM REPAIR ❑ _ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK L _. SEWER LINES} DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial CI Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ,F ❑ Public ❑ Other E -�-❑ Delta Depth of Grout Seal Type of Grout LlIrrigation �pprox. Depth C1 Eastern _ Surface Seat Installed by+ Repair Work Dane ❑ Type of Pump N.P. State Work Done_ Well Destruction ❑ Well Diameter. F Sealing Material (top 501 Depth l Filler Material (Below 50') �1 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl t REPAIR/ADDITION ❑ DESTRUCTION�QeMo septic system permitted if public sewer is ie /available within 200 feet.) Installation will serve: Residnce_ 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. ❑ I� r Method of Disposal Distance to nearest: -Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �I 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 f 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 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 shall employ persons subject to workman's compensa- tion laws of California." 4 The applicant ust call for ail quired in Spec ions. Co late drawing on reverse side. i 4 a Signed X _ Title: 0 L./ e1., Date: -2 — V7 FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Date inal Inspection by Date Additional Comments: / �. ❑ Stk 466-67$1 b Lodi' 36g-3621 O Manteca 823-7104 ❑ Trac 835-6385 L . Y ^� . Applicant- Return all copies to:-Environmental Health Permit/Servipes 1601�j Hazelton Ave., P.O. Box , Stk., A 95201 INFO "AMOUNT DUE ArQbufNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. + £H 1428(REV.i/s 51 �, '�-�'^'_(3� S`�� F�'r 3`r�� ' +. J i V {