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APPLICATION FOR PERMIT r _ SAN JOAQUIN LOCAL HEALTH DISTRICT mitis ' " 1601,E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466-6781 + PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . 41-• ,: (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. �7 Job Address / /J'� 5 / T11, -T CityXA~Lot Size PM Owner's Name t1 ,4ddress l�v� � ,� Yom . _ Phone Contractor ;Address_OZZp?a RZ?License Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ifs r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Xf i Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Hone ❑ Type of Pump HP. State Work Done_��l1L.L AfDN�4 TII,P,g/N� Well Destruction1.�:Well Diameter � Sealin a ena topIF _ 1U �_Ni . Depth .i i - Filler Material-(Below 50'), i��. TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION L1DESTRUCTION ❑ {No septic system permitted if public sewer Is available within 200 feet./ Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth R SEPTIC TANK ElType/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal � c c Distance to nearest: _Uw611 "-n Foundation'`-""'"% Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation v- I :N�- "Property Line SEEPAGE PITS ❑ Depth Size "Number SUMPS €' ❑ Distance to nearest: '- Well Foundation" ""f Property Line DISPOSAL PONDS ❑ I hereby certify that l 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. i 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."-Contiactoes airing 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 all r pections. Complete drawing on reverse Signed of Title: Date: F R DEPARTMENT USE.ONLY ^i Application Accepted by iL Date- Area --- f� (0"-1 7 Pit or Grout Inspection by � Date Final Inspection by � Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE 1 I INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. + EH14.241REV.t/851 EH 1428 LOO