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• �� ' I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6791 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 County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address -JQ / x.J V )"fW�.- City/ ' _ of ize PM X r�n �e 6 S6 1 . L/J Owner's Name Addre �!I�Lx/_l��fJ�U —+-�" ss Phone s 1 t !� ' Contractors ddress 1 � /V License Na/ 97Phoney VF one TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial - ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing Cl Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications {9 Public - fl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _-_Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Material(Below SO1 TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is • ',le ithi 2DOq feet.) � SACS installation will serve: Residence�Commemial_ Other T�^ Er/TT_7�'l�(,_ Y Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: In Water table depth SEPTIC TANK ❑ Type/Mfg Capacity . o a No. Compartments PKG. TREATMENT PLT.❑ ^ Method of Oi Distance to nearest: Well S`d 0 Foundationy Property Line LEACHING LINE 0 No. S Length of lines J Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 0 Foundation Z 0 Property Lure A. SEEPAGE PITS I I Depth Size n Number SUMPS LI Distance to nearest: Well ,rz - - Foundation . __ Property Lire 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 sub-contracting signature certifies the following:"I canify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compams- tion laws of California." The applicant rrlyst call for all rgquired in tions. Complete drawing on reverse side. pn 1//j /-y !M lic Date: �`'e�b�LS I Signed N /�s+'t n! - J-f.e"'V- Tele: ��"L — �FOR DEPARTMENT USE ONLY l -a o- Application Accepted by Data Area 7 Pit or Grout Inspection b Data Final Inspection b`y, Date il,�gjatU�yr/�! Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 829-7104 ❑Tracy 835-6385 • Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CCA9H RECEIVED BY DATE / PERMIT-NO. .EH13.24 IREV.Vxel EH 14-26