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P e►4. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTS i 1601 E. HAZEL T ON AVE., STOCKTON, CA NO W Telephohe (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED vk4 (Complete in Triplicate) t v� 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 /�^� � -3 �� ,._ City Lot Size PM Owner's Name A Address Phone ` Contractor Address � t H License Na � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI LD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing ❑'Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing Specifications M Public r Il IJelt�a r4 Depth of Grout Seal Type of Grout I I-Irrigation --Approxi Depth I I Eastern rE. Surface.Seal Installed by 1 Repair Work Done ❑ Type of Pump IV H.P. State Work Done t Well Destruction ❑ Well Diameter j Sealing Material (top 501 - �� Depth ! "" —Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION 11 "REPAIR/ADDITION {.l DESTRUCTION` INo septic system permitted if public sewer is { e + { 1 vailable within 200 feet.) Installation will serve: ResidenceCommercialA `Other}-- Number of living units: ,Number of bedrooms - s Character of soil to a depth of 3 feet: j`�"""-"""`Watei table depth SEPTIC TANK ❑ fypey M g Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 ; t' Method of Disposal Distance to nearest: Well Foundation ' Property Line LEACHING LINE ❑ No. & Length of lines t Total length/size f7 FILTER BED ❑ Distance to nearest: Well _Foundation_— Property Line I SEEPAGE PITS ! I" Depth ` Size Number I Q r SUMPS Cl Distance to nearest: ` Wel( Foundation Property Line DISPOSAL PONDS !❑ f 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 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 must call for all required inspections:.Complete drawing on reverse side. Signed K Title; ' r Date: { F CWiPARTMENT USE.ONLY I Application Accepted by _ Date [�d�V—e Area Pit or Grout Inspection by Date Final Inspection by at +=~LM (}f ( s Additional Comments: 1 �� 9 3 $..17C�fc� 1 � Ttc/ t-Uf �ci _ ❑ Stk "466-6781 F) Lodi "369-3621 ❑ Manteca 823-7104 ElTracy835-6385- i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk.,tA 9501FEE a K 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED B DATE PERMIT NO. i.EH 13.24 IiiEV.I/x sf { C { EH 14-28 73:,