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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 and Regulations of the San Joaquin Local Health District. n y Job Address yy L� _ City Lot Size 1Q S` PM Owner's Nameyk - VD' 1 Q.- Address Phone M� Contractor/ �um�1ri� Address?v,T .f7C =�JG� -P1 License No. Phone TYPE OF WE=LL/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 INTFNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing L-7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other C-) Delta Depth of Grout Seal Type of Grout - �0 I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Q Repair Work Done L7 Type of Pump H.P. State Work Done Q . Well Destruction_- ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-* Commercial Other Number of living units: 1 Number of bedrooms Character of soil to a depth of 3 feet: Water table depth QCV 79r I SEPTIC TANK '* Type/Mfg Capacity Clb No. Compartments PKG. TREATMENT PLT. ❑ Method of Dlspwaq Distance to nearest: Well �� FoundationS Lo /00 Property Line �� LEACHING LINE No. & Length of lines . Total length/size _p e FILTER BED ❑ Distance to nearest: WeII500 Foundation Property Line-75 SEEPAGE PITS I 1 Depth Size _ Number PSP L1 Distance to nearest: Well Foundation Property Line OSA NDS ❑ hereby certifyt I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulation f the San Joaquin Local Health Di1trict. Home owner or license ent's signature certifies the following; "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in such nor as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify t in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion iaws of a ifornia." The applic t ust call a!I re ed ins tions. Complete drawin reverse side. Signed Title: Date:27 "L'L �FORTMENT USE ONLY Application Accepted by Date �-�2� 6�� Area ® it r Grout Inspection by� Date �� 1' Final Inspe by/ Date Additional Comments: - f�fZ_X 10 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO. INFO !j CASH r� +.EH 13-24 IREV.i/n 5) `?N , I ,D D l I e O 0 �t C7� � —aq—q 2_ l A y ~2 5 EH 14.26 1 r