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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone Q09) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (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. At � Job Address Z �3 +0 11 City e-00„0 Lot Size PM J Owner's Name t Address Phone 17 Contractor 61 T14 GQO�S_ Address a a License No377384 Phone r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP iNSTALLATIONIZ SYSTEM REPAIR ❑ OTHEfi ❑ DISTANCE TO NEAREST: SEPTIC TANK I _.-. SEWER LINES DISPOSAL. FLIA Sr PROP. LINE LAW �n FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOW L I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V Domestic/Private .Gravel Pack ❑ Tracy Type of Casing &VC Specifications _ ` .-�- 1-1 Public CI Other ❑ Delta Depth of Grout Seal S Q Type of Grout E I Irrigation 'k',,�...Approx. Depth l 1 Eastern Surfaec�Seal Installed by CDNT_P, aC'k3rP Repair Work Done ❑ Type of Pump _ryrl t_ H.P.----/ - T State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 Dii§ttict. 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 perfof mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. o. Signed X Title: Jd(AZX&,r _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date l / Area �— Pit or Grout Inspection by Date Final Inspection by � Date/40`96Y Additional Comments: Q f—; 79 0 Stk 466-6781 ❑ Lodi -3621 Manteca 8231104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE RECEIVED BY ATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED G Q INFO CASH � //J� /4� +-EH 13-21(REV.I/n s) ! F 6 0 / P 66 /LJ w / J, f `U � EH 11-28. �_i 'P i {