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I APPLICATION FOR PERMIT ) ' SAN JOAQUIN LOCAL, HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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 /7S`2 SMV..,-0,t O V ' City Lot Size 1JA/or PM Owner's Name �'i4.vi¢R!a iN o Ai[?o~�'Addrass /7 1_z s74�✓.�'o�eD f! Phone 73/ Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.____ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ,-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter f Sealing Material (top 501 Depth Filter Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X DESTRUCTION ❑ (No sepfic system permitted if public sewer is Iavailable 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: A� _ -Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ _ Method of Disposal k Distance to nearest: Well Foundation ` Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: /� �r��undation Property Line lr l SEEPAGE PITS EJDepth 1S'iT. Siz Number SUMPS Distance to nearest: Well "C W4015915& Property Line DISPOSAL PONDS ❑ 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 licansed 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 inspe I ctions. Complete drawing on reverse side. Signed Title: 0 4c/tf�E`/C Date: / i ,FOR DEPARTMENT USE ONLY l Application Accepted by Date ' 3" Area S Pit or Grout Inspection by Data Finalnspection by Date EX! !ri a,v� tr� us-4uanr�[ Q�nd �o`j'�,p vie Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385f Applicant- Return all copies to: Environmental Health Pemtfi/services 1601 E. Hazelton Ave., P.O. Box D9, S11 ., CA Ot AFEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. + EN 1321(REV.10/831 et 1426 1(-13 —?q / EH �Vy �3"r