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APPLICATION FOR PERMIT e SAN JOAQUIN'LOCAL HEALTH DISTRICT c , . 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE IS§UED (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 Rqles and Regulations of the San Joaquin Local Health District. /�C.� rc l ( l�ST City Job Address 9 Lot Size PM ' Owner's Name /O/�J%ir,C J Oy�f� . .. Address 4'mow'- it r • 7P " _ Phone Z . Contractor_gA /-(L Address ALI& oM9VV9X License No. 3 Z Phone TYPE OF WELL/PUMP: NEW WELL AAA❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK \ SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONSPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications ❑ Public ,�❑.�OOtt•�h" parr C] Delta Depth of Grout Seal 'Type of Grout_ [: Irrigation _LApprox. Depth P Easternurfara Seal Installed by Repair Work Done EJ Type of Pump H.P. �;[7 State Work Done Well Destruction ❑ Well Diameter 1 7 Sealing Material Itop 5V) 1 Depth Filler Material 18elow 601 ..TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION El El (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 "No7Compartmanta 1 PKG.TREATMENT PLT. ❑ _ %Method of-Disposal Distance to nearest: Well Foundation Property Line. t LEACHING LINE ❑ No. & Length of lines Total length/si ` I' FILTER BED ❑ Distance to nearest: .Well Foundation Property Line SEEPAGE PITS ❑"—Depth - Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ 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. - 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 subcontracting signature i 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- tlon laws of California." The applicant m t call rnr wFre fired inspections. Complete drawing on rse side. j f Sighed Title: :Date: 7_t� /'- FOR DEPARTMENT USE ONLY Application Accepted by r Date 0-` 'i Area Pit or Grout Inspection bry - Data Final Inspection by Dote/ ,t Additional Comrtranb: - - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mentace..823-7104-- +❑Tracy"i � ' Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hatslton A".. P.O. Box 2009, Stk.,CA 95201 FN EE AMOUNT DUE AMOUNT REMITTED K t�RECENED BY, DATE PERMIT-140. INFO R v L(JN1 i. IA�f -7♦EH a241REV.r/a /, EH 1ate � T RSM