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r ' 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 (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. i /� oXI� � Job Address �ta4 W�/11GG/� Sr-_ City �� Lot � PM { Owner's Name D o A&!_ & %4K 5 .Address Phone Contractor FL-0Y1) _Address rZ A1'. ASE L6ElF'T License No. !LSr 7� 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public F1 Other •Cl Delta Depth of Grout Seal Type of Grout I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') �_ C TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION DESTRUCTION f I (No septic system permitted"if pt7tilic sewer is 7777-7` / available within 200 feet.l Installation will serve: Residence `� Commercial_ Other Number of living units: ---/— Number of bedrooms Character of soil to a depth of 3 feet: t�f f1!!-�` Water table depth SEPTIC TANK ElType/Mfg X 1 S 7�`/1 � Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines ¢67 Total length/size O f FILTER BED ❑ Distance to nearest: Well JZ t Foundation Xy ' Property Line S� SEEPAGE PITS l Depth �S r Size Number � SUMPS Cl Distance to nearest:------Well 40_-O_-- - Foundation 72 Property Line S r DISPOSAL PONDS El 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 X� Title: `_ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date — Area it r Grout Inspection by Date %Z Final Inspection by.IW_ b Date Additional Comments: LI Stk 466-6781 ❑ Lodi--369-3621—❑ Manteca---8237104 -C] Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S[k., CA 95201 INFOFEE AMOUNT DUE AMOUNT REMITTED RRE-CEI—VED BY DATE PERMIT'NO. ♦. (REV.s/x 51 EH 14-26 .� / .7,5;9 Q 1 Q ��--//�\ .C'6 4 t f l J�j