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V - ��i 6r7 9•�r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 06f 7LJxx � City i=/9XA Lot Size Zee! lPM Owner's Name Address Phone E Contractor's Name vf�-�Q�� License No. S 5/ _7 r�f-� Phone W TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ trf OTHER E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLQ. PROP. LINE _ FOUNDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS {(Te 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 ' r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout • ❑ Irrigation ---Approx. Depth�.❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 3x N.P. / State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') S I Depth Filler Material (Below 50'i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system=permitted,•if public sewer is 7 available within 200 feet./ Installation will serve: Residence 12!� Commercial— Other Number of living units:_/__ Number of bedrooms Character of soil to a depth of 3 feet: )!!fWater table depth SEPTIC TANK Ifr Type/Mfg .�4 9 R I Capacity��®D No. Compartments -' PKG.-TREATMENT PLT. ❑ d Method of Disposal k Distance to nearest: Well A040 Foundation Z0 Property Line p LEACHING LINE F,,.,_„ _No._&_Length of lines, x Total length/size 7 FILTER BED ❑ Distance to nearest: WellZino- /. Foundation /V / . Property-Line, S SEEPAGE PITS L?-"DepthZia ' Size 174 .._ NumberA SUMPS ❑ Distance to nearest: Well Oundation /040 f, Property Line DISPOSAL PONDS ❑ 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 �Y 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 e 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." 71 1 k l-The applica us call for all required ins s. C mplete drawing on feverse side Signed Title:— __ Date: r FO DEPARTMENT USE ONLY f Application Accepted by . _ Date— /� Area ` Pit or Grout Inspection by CaQa"� _I�f� Dat -sy Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3699-3621 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. + EH 13-24(REV. 10/831 R41-5_7 g EH 1428 S