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p 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 1-t (Complete in Triplicate) Ir.-_P,,w L"t 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. f� Job Address _l �P �tC� �x;p n5- CityJ�C}��QN Lot Size SC_ Ply Owner's Name 'Io, �� 1 Xe[+5-a- Address' E -3ri Phone { Contracto 1 �Yal. Address License Ko.. P_hane �� 1 TYPE OF WELL/PUMP: NEW WELL`❑ WELL REPLACEAAENT ❑ ""- I?E57RUCTlON i S PUMP INSTALLATION vi . �` rr �.__ w e i ,.,�,. �► E'`- SYSTEM REPAIR.Q�+�-'5-a OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i 'FOUNDATION- --AGRICULTURE WELL OTHER WECI,7 F "I'PITS/St1AAPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open•Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ;Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications S El Public 11 Other LJ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by { Repair Work Done ❑ Type of Pump H.P. H F State Work Done , (� # Well Destruction ❑ Well biometer Sealing Material (top 50') , 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.► 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 F �, Distance to nearest: Well Foundation Property Line J i < LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 1 Depth Size` Number SUMPS I ❑ 1 Distance to nearest: Well �"' Foundation' Property Line 1 DISPOSAL PONDS F1Y�t e r ¢4 I hereby certify that I have prepared this application and that the work will be done iri accor-da ce 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 sigriature-certifiesIhe 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." The applicant m t call r all ed inspections. Complete drawing on reverse side. € Signed Title: Date: r FOR DEPARTMENT USE ONLY # Application Accepted by2 Date Az�� G G _ Area Pit or Grout Inspection by Date Final Inspection byDated'. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 1 A1. } FEE AMOUNT DUE AMOUNT REMITTED 5 +. f INFO CA RECEIVED BY DATE PERMIT"IVO. Q/ , Qj �W.. + EH 13Z24[REV.1�a 5} �,. ._. EH 1428 ^0 c