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... zt APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �1�' 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 ffi"b C: City =57—k PJ r Lot Size PM _I A e Com'i L G Address 3Owner's Name G� mv�c Phone / f �iSN�S�SAddress �0�. �Lcense No. PhoneContracartl, A. G _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a 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 _E.I.Manteca Dia_ of Well Excavation, pia. of Well Casing LlDomestic/Private h ❑ Gravel Pack 11 Tracy Type of Casing .1 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout El Irrigation € _—Approx.. Depth ❑ Eastern Surface Seal Installed by "I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction '❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ fNo septic system permitted if public sewer is r % }ti available 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.. - I f' r- ' ` � Water table depth SEPTIC TANK1_ Type/Mfg Capacity No. Compartments } s PKG. TREATMENT PLT. t 1 i Method of Disposal Distance to:nearest:--Well— f Foundation I Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance 'to' nearest: Well Foundation Property Line a SEEPAGE PITS 1Depth Size6;1 - Number .. f , SUMPS ❑1...Disfance to nearest: Well Foundation Property Line DISPOSALPONDS 1-1 /_T��i I 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 orsub-contracting signature certifies the following: "I certify that in the performance of the work for-which this permlf'Is issued, I shall employ persons subject to workman's compensa- tion laws of California." ' s '" `" The ap licant m II for all re ins tions. Complete drawing on reverse side. }� Si ed Title: Date: � y FOR DEPARTMENT USE ONLY Application Accepted by Date T �� Area ,. Pit or Grout Inspection by �I Date Final Inspection by fi7�, Date6"(VI�7 Additional Comments: r' f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca .823-7104 C1 Tracy 8354M 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 CCK RECEIVED BY DATE PERMIT'NO. + EH 1324(REV.1/a 5) ,Q�'�� • r _ /� �^�1� i Eli 1 -28 (r"• fJ (.J / j