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` APPLICATION FOR PERMIT �f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �M Telephone (209) 466-6781 PERMIT EXPIRES'1`YEAR FROM DATE ISSUED 3 .,,�.,. (Complete in Triplicate} }i Fi 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 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. v�. 4_ M •� - .0 Job Address J -�; . 5110 vem c "ZV Cr City, Lot Sizec PM �I L 1 ` Owner's Name - =Address Phone � '- C)C� J� —• ' ' j�c9- , ! . _ 3 l Contractor JM.x e_4-� Address License No _�Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ;K SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing KDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other\` LJ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 'Approx. Depths❑"Eastern Surface Seal Installed by IM Repair Work Done ❑ Type of."Pump! f J-� P. State Work DoneiV Well Destruction EDWell Diameter ` Sealing Material ►top 501 a ,� Depth � Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION-El `REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is j0 I available within 200 feet.► Installation will serve: Residence Commercial—`--Other,,, Number of living units: Number of bedrooms ! bs Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg A Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I� FILTER BED 17Distance to.nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth P `f Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that "have-prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, and rules and regulations of the San Joaquin Local Health District. !I 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." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of-the-wor_k for which this permit is issued, I shall employ persons subject to workman's compensa4 tion laws of California." ~ .,I . The applic II for all.re,Tired inspections:Complete drawing on{ verse side. Signed Title:t Date: FOR DEPARTMENT USE ONLY Application Accepted byr �l/'- Z)7 Date Area 17 Pit or Grout Inspection by `� Date Final Inspection by Date / II Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621' ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE j INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED.BY DATE PERMIT"N0. + E1 -24{REV.1/857 121-11- utf/� I SUY� EHH 1428 +