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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y; (Complete in Triplicate) f `' 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 iso, made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. ; - Job Address ? r 1 ..> City' c zt'{: Lot Size 0/0 / uta° PM s r r _ Owner's Name 7 2 � f2Lv�c Address f hi Phone 3 ., ; e i Contractor �'j - Address C �� .C`ixrt� License No. •��,7, Phoned r TYPE OF WELL/PUMP: NEW WELL ❑ WEL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR I OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE • FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ,C7 Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ElGravel Pack F-1TracyType of Casing f Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal' ` Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by j n Repair Work Done ❑ Type of Pump f H.P. E State Work Done # Well Destruction ❑ Well Diameter Sealing Material {top 50'1 ' Depth Filler, Material (Below 60') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI DDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is / - available within 200 feet.) i Installation will serve: Residence✓ Commercial_•,Other Number of living units: Number of bedrooms `-fit r. " -,Or Character of soil to a depth of 3 feet: y _ t - Water table depth SEPTIC TANK DY'_Type/Mfg - Capacity Say. 51—:'No. Compartments I- y PKG. TREATMENT PLT. ❑ jC �G'G� �'A- y Method of Disposal Distance to nearest: Wel! �� ,Foundation le Property Line LEACHING LINE I" No. & Length of lines Tote/ length/size < ' FILTER BED ❑ Distance to nearest: Welll_.5_,O Foundation Z-d� _ Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest:"` Well Foundation ' Property Line DISPOSAL PONDS ❑ III 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" 1 rules and regulations of the San Joaquin Local Health District. I 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." Contractors 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 Cafi#ernia.`1 .�-�- � The appli nt mu t c I for all requir pecfiorls plete drawing on r erse side. 1 J 1 Signed Title:_�//L-C�"Yl�7 Date: 7-1'2r'�-� � FOR, DEPARTMENT USE ONLY ` i F Application Accepted by i -Date 7 Y ea Pit or Grout Inspection by - Da tey Final Inspection by -77 Date Additional Comments: ° I ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 LJ Tracy 835-6385 Applicant- Return-all copies to:-Environmental Health'Permit/SdrAC9,8 1601"E.J Hazelton Ave., P.6-113 o-x 2009,Stk.,CA 95201 1 FEE _AMOUNT DUE yAMOUNT REMITTED CK RECEIVED BY _DATE _ PERMIT•`N0. rar..... .INFO.- ..... .p.. _ + EH110.26 3-24(REV.t/B 5) EH � � �- .±. •�� / ?9-F3& , /'C7 J. 0].. / P