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�✓ 5 I APPLICATION FOR PERMIT 7 E� SAN JOAQUIN LOCAL HEALTH DISTRICT 0�1 1601 E. HAZEL T ON 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. � Ji Job Address � �r/ Z_ City Lot Size ( d PM Owner's Name�e L?�' d Address a - 4✓` Z Phone J4 ^ / Z' '7 % a e AJ ?3a v f --- Contractor ��'�� Address .S License No. Mo e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ D STRUCTION ❑ t PUMP INSTALLArT ON ❑ SYSTEM REPAIR ❑ OTHER 6L>r'I`SP.rtl P ti DISTANCE TO NEAREST: SEPTIC TANK /D SEWER LINES DISPOSAL FL PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation * Dia. of Well Casing GI Domestic/Private r ❑ Gravel Pack ❑ Tracy Type of Casing J�Yr��` Specifications 1-1 Public ❑ Other I=1 Delta Depth of Grout Seal " -"' Type of Grout _ + I 1 Irrigation T_Approx. Depth l I Eastern Surface Seat Installed by _ I Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is l I1 available within 200 feet.) VV" Installation will serve: Residence_' i Commercial_ Other .�, t 'a ) Q Number of living units: C Number of bedrooms t Character of soil to'a depthfof 3 fee0_.-- Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y I PKG. TREATMENT PLT. ❑ Method of,Disposal Distance to nearest: We11'-'"" " FIoundation ^"Property Line- LEACHING LINE e 0 No. & Length of lines ; ' ^'ti "^. Total'Iength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' ? • SEEPAGE PITS 11 Depth size ` Number f SUMPS ❑ Distance to nearest: . Well Foundation. Property Line 4 DISPOSAL,PONDS ❑ 3 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 t 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 thelwork for which this permit is issued, I shall not i employ any person in'such manner as to become subject to workman's compensation taws 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 C lifomia." --- —�-- --.v The appfica must call f II requd'inspections. Complete drawing on reverse side. q r Signed X Title: �w+�CJ�2 Date: 1---w- /o i FOR DEPARTMENT USE ONLY J� } Application Accepted by ____ Date Area C _ Pit or Grout Inspection by y .r H Date Final Inspection by Date Additional.Comments: Sf tb vtirf w�Cr,t.. MLS f4AfQQ& 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 &Uracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. I + EH 13-24IREV.t/A5f EH 14-26 —h i I