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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT j / `, 1601 E. HAZE I ON AVE., STOCKTON; CA -3 C 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. Job Address p23 I'!Z �7ctl/&,- 7- /^ City 5 "70 t Size PM S Owner's Name "'s �-[.�/.',�°9� C ��lC Address es F �{,s14ti 7 Phone Contractor ,/J�t/r.G l�C✓ /` AddressLicense No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT .❑ DESTRUCTION 0- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �. OTHER`❑ DISTANCE TO NEAREST'SEPTIC TANK. •x � SEWER LINES` T _ DISPOSAL'FLD. PROP. LINE FOUNDATION A AGRICULTURE_WELL . OTHER WELL PS INTENDED USE TYPE OF ROBLEM AR w ON_SPECIFICATIONS - t a— ❑ Industrial - -❑:Open Botto anteca- .-of Well Excavation --- Dia. of Well Casing ❑ Domestic/Private avel Pack ❑ Tracy Type.of Casm z Specifications i M Public ❑ Other f 1 Delta`. Depth of Grout Seal Type of Grout I I Irrigation __--Appiox. Depth ' t I Eastern Surface Seal Installed by.... u ` Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') -'- Depth Filler Material (Be 501)•i ` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONI DESTRUCTION (N septic system permitted if public sewer is ,/ ava table wrthin`200 feet.) Installation will serve: Residence T Commercial Other v Number of living units: ___h__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg lJRt`clt Ca atilt p Compartments r PKG. TREATMENT PLT. O '4 / �. Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size {J + Jj FILTER BED El Distance`to nearest: -Well a a Foundation _ Property Line — SEEPAGE PITS 11 Depth, Size_= 30` Number r SUMPS Cl Distance to nearest: Well `4/0 Foundation (_ Property Line 30 lQ� DISPOSAL PONDS ❑ t 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 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 cal-for all required inspections. Complete drawing on reverse side. Signed `� t/n;n � Title: — f/AZ10 Date: FOR DEPARTMENT USE ONLY I Application Accepted b PP p YDate Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: . a/lr-.- • �!�"-� I .,� + f 4V0�.✓' ❑ Stk 466-6781 , ❑ Lodi -3621 ❑ Manteca 823-7>fOO4 0-Tracy 835-6385 ( f 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 CK CASH RECEIVED BY ` DATE PERMIT NO. +.EH13-24(REV.t/x5) 35GD -3SM6 EH 14-26 - ��'� - /A y