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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 Cdunry Ordinance No. 5A9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. +1 I Job Address J �1�a &U7d p City � /� Lot Size PM_ Owner's Name © IL C �z`-r ' Address 3 �"T / f +r�Q Phone (016) Z6 pi J Contractor Address-93a, ` ice Nv. S S e—! 7 Phone /6 3 - Z )( TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE�M}} REPAIR ❑ OTHER ❑ -T DISTANCE TO NEAREST: SEPTIC TANK _SEWER LINES 4o' DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL 50� PITS/SUMPS _ INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation O N +� � � Dia. of Well Casing Domestic/Private f �� Gravel Pack I� Tracy Type of Casing g 11 If C. Specifications r-] Public ❑ O,her (� pelta Depth of Grout Seal �2o1k Type of Grout I I Irrigation t `�Approx. Depth I I Eastern Surface Seal Installed by eo hta1C Repair Work Done•! ❑ Type of Pump H.P. State Work Done _ � { Well Destruction ❑ Well Diameter Seating Material atop 50'} Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other - r Number of living units: Number of bedrooms r Character of soil to a depth of 3'feeu } 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 "v Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS f I Depth Size Number SUMPS ❑ Distance to"nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this # rules and regulations of the San Joaquin Local Health DI-Strict. # 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- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X g7Xt Com" Title. / Date: p FOR DEPARTMENT USE ONLY A a C13 Application Accepted by y( Date Area Pit or Grout Inspection by Date 6 Final Inspection by . , Date f Additional Comments: r✓C.C.S a T Z A?b ❑ Stk 466-6781 ❑ Lodi 369-3621; ❑ Manteca E123-71b4 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE Q PERMI7'N0. ♦.EH 13-24(REV.r/H5Y EH 14-28 •�1�,/ _ /93�r GJ J 6 //