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•� APPLICATION FOR PERMIT T iV SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,.STOCKTON, CA 7�4_// Z41 .. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate). 'u E12— 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 Or - ante No.54,9 fir sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin , Local Health District. 7,C.f�+tlf ( I ! ._I Sf X ?moo d Job Address- �ZASS,c— �"�LL�f�IFG !-City Lot Size PM Owner's Name F1� HC �1 _ Address � - � S EL� Phone C)- t Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing 3 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout EJIrrigation r ----Approx. Depth• ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic system permitted if public sewer is available within 200 feet.) �. f ` 4 Installation will serve: Residence� Commercial_ �Other Number of living units: Number'of bedrooms, j Character of soil to a depth of 3 feet: t Water table depth 7r SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line s t LEACHING LINE r ❑ No. & Length of linesTotal length/size FILTER BED ❑ Distance to nearest: Well { Foundation Property Line SEEPAGE PITS it ❑(Depth ? t7 Size T r + r Number ■ vd. , + J I SUMPS ❑ Distance to nearest-.• Well Foundation - ,Property Line DISPOSAL PONDS ❑ M" R YAi/ 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 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." 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 ust call for all requir d inspe tions. Complete drawing on reverse side. Signed / Title: Date: FOR DEPARTMENT USE ONLY 2 /� Application Accepted by Date Area v Pit or Grout Inspection by Date Final Inspection by Date�O Aitional Comments: JAStk 466-6781 - —❑_ Lodi 369 1,...e•_,_❑.Mant ca. -7 04,,,4;_ —❑Tracy.•-.835-B385m.— Applicant- Re urn all cotes ta.- Emw-nmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 'PAVe INFO AMOUNT DUE AMOUNT REMITTED FEECK H RECEIVED BY DATE PERMITNO. + EH13-24 IREV.v H 51 ' I EH 14-28 33 1 L!3