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�.s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67817 I PERMIT EXPIRES 1'YEAR FROM DATE ISSUED RUG N�AL�H (Complete in Triplicate) jteI � P,�, �Ctg Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workol��21 qg��1V `16* s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and ions of the San Joaquin Local Health District. Job Address 's`iL----4� Lu iya ity Lot Size PM '77Owner's Name ��I�1� Actress 4� / Phone �y�/� 1 Contractor I ! I l ddress c� License No. L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR)f OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Tmpg of Casing Specifications I1 Public 11 Other n Delta Depth of -e 111- ----_ _ Type of Grout !'Irrigation "- '�-�-.�..__Approx. Depth I 1 Eastern Surf-a � Seal Installed by �^l~ Repair Work Done ❑ Type of Pump H.P. 7�" _ i State Work Done LQ� N1� Well Destruction ❑ Well Diameter Sealing-Material (top 501 050 --Depth _ Filler Material (Below 1""1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION-11 REPAIR/ADDITION I 1 DESTRUCTION I I (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 ._ `i �1, 11 - W raterate table depth SEPTIC TANK O*'�Typ�M1` Capacity No. Compartments PKG. TREATMENT PLTt" / Method of Disposal Distance to nearest: Well Foundati, Property Line'"- ! - LEACHING LINE ❑ No. & Length/f'line� Total length'/si e �C'i. s FILTER BED ❑ ! [ istance to nearest:). r, 111le11 `Foundation r Property�ge SEEPAGE PITS I i Depthy Size Number SUMPS ❑ bistance to nearest: Well ,�" Foundation Property Line DISPOSAL PONDS j,O. \ �- I hereby certify that I Have prepared this.application,w .th. t il'(e work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulationslof the San"Joaquin La`cal Healtfi'�bistrict. �. • r - Home owner or licer sed agent's�signaure certifies-thd'following: "I certify that in the performance of the work for which this permit is issued, 1 shalt not employ any person in such manner,aslto become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I ca'itify 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." \Yj The applicant u qutred ' s. Complete drawing onrev rse side. Signed X itle: � ` Date: FOR DSP RTfMEf11T USE ONLY 7- 06-T Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection bye_ ` Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMO,UyNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-N0. ♦.EH 13-24(REV.I i H sl EH 14-26 L/ t