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PA fL C=0 i k 0 -7 � APPLICATION FOR PERMIT I59-7Pr--Tef SAN JOAQUIN LOCAL HEALTH DISTRICT LU7 z� 1601 E. HAZELION 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 andations of the San Joaquin Local Health District. p�j g�.�C--5 /7 Job Address City Lot Size �G PM Owner's Name F7,0 L ` Address Phone r _ Contractor's Name rCZAZZEe License No. 6 �L�� Phone IlfeeA.3 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth T1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material (top 50') e _ Depth - Filler Material {Below 50'} i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if•public�sevver;isw .—� available within-200,feet.) Installation will serve: Residence Comrrteicial_- the"rte Number of living units: Numberof be i Character of soil to a depth of 3 feet: Water table depth ! SEPTIC TANK Type/Mfg Capacity„gotv 'No. Compartments { PKG. TREATMENT PLT. ❑ ` '-Method of Dispo 3 i Distance to'nearest: Well /V[sJViF' Foundation f� Property Line LEACHING LINE No. & Length of.iines2 Total length/size FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line ' SEEPAGE PITS ❑ Depth "Ayr—, Size �{�71l /O Number "f SUMPS Distance to nearest: Well Foundation _ Property tine la1>1 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 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 I requ' d inspections. Complete drawing on reverse side. Signed T� Title: Date: �� FOR DEPARTMENT USE ONLY _ Application Accepted by Date klu Pit or Grout Inspection by ate Final Inspection by f Additional Comments: 0 Stk 466-6761 it ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy-835:685 Applicant- Returri all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I F FEE AMOUNT DUE AMOUNT REMITTED w CASH RECEIVED 8Y DATE PERMIT-'NO. INFO t Q + EH 13241gEV,10/831i P `Lw 0 - EH 14-28 415 <�,0 c7� 1'E