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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA II Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED (Complete in Triplicate) i Application is hoieby 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. 1✓/GT1rQ Job Address 0-� City Lot Size r46�0_ES PM ! i SQ7L57-AGE 77 910 Owner's Name - Address �O 4}t" 7�8 . I/!G 717 fl. 64 Phone 3'514- A 4)? Contractor P L-O`/D L . Loc leo D Address 7117, 09-4/Z' License No.!,�7 17-74 Phone s 3 7 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 El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'I Public H Other ❑ Delta Depth of Grout Seal Type of Grout i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ 1 Repair Work Done D Type of Pump H.P. State Work Done_ l Well Destruction 0 Well Diameter Sealing Material Itop 50') Depth - -- - - --Filler Material-(Below-W) Q TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION .X DESTRUCTION I I (No septic system permitted if public sewer i's ;^ I available within 200 feet.) Installation will serve: Residence ""' Commercial Other Il Number of living units: I Number of bedrooms . 4 Character of soil to a depth of 3 feet: S'.4x-lp!e /P1 Water table depth SEPTIC TANK ❑ Type/Mfg EX I S i/f iCT Capacity No. Compartments Y PKG. TREATMENT PLT. ❑ y '1NetHod of Disposal ' Distance to nearest: Well Foundation Property Line / 7 LEACHING LINE \& No. & Length of lines " ).00 Total length/size ang FILTER BED �0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS it) Depth 149 Size 0-- X 1-2- Number Z^ SUMPS X Distance to nearest: Well��s r Foundation p 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, f 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-0 tion laws of California." The applicant must call for all requited/inspections. Complete drawing on reverse side. � I Signed X -�.1 Title: Date: S� 7—g p FO DEPARTMENT USE ONLY App' ation Accepted by Date Q Area or GrVkspection by Date eFinal Inspection b Date�� T ` Additional Comments: [ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED - RECEIVED BY DATE PERMIT'NO. - INFOfir CASH ♦.EH73-24(HEV.i/n51 20 OV �0 EH 1426 �V! � + t