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r J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-67$1 y_ II PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) k EV AERplication 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. i i 1�Oye CA'f'y0,4 To . . �if/VGIy PM Joh Address N f!� - City 3"G�l�O.O� Loi Size 'i 'i Owner's Name -Toe 0 d�'�4 V C'3 Address yy e19YYd t roiV 4W. Phone � Contractor Address 4400,4QL�'�` �' ` "5 p License No. �yy S"�/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ;s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A fl Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r M Public n Other Cl Delta Depth of Grout Seal Type of Grout _ I Irrigation ApproK. Depth I I Eastern Surface Seal Installed by Rfpair Work Done ❑ Type of Pump H.P. State Work Done _ s Well Destruction D Well Diameter Sealing Material (top SO') 4! Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION kf REPAIRIADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is S available within 200 feet.! I I ,_ )Installation will serve: Residence! Commercial Other iNumber of living units: Number of bedrooms x ' I `Character of sail to a depth of 3 feet: fA � Water table depth SEPTIC TANK JZ Type/Mfg &e G. .ir Capacity l oo No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well d0 ' Foundation z-r Property Line S' i i 1 LEACHING LINE Z No. & Length of lines -" ys Total length/size �p } FILTER BED ❑ Distance to nearest: Well Foundation Property Line rl SEEPAGE PITS I I Depth Size Y.1, Number SUMPS [A Distance to nearest: Well �!Z�� Foundation �� Property Line s� -- D;ISPOSAL PONDS ❑ Ihereby 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 certify that in the performance of the work for which this permit is issued,1 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 Title: Date: OR DEPARTMENT USE ONLY Application Accepted by 4_ Date !-" Pit or Grout Inspection by Date Final Inspection by Date �� y Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.. CA 95201 L LLI 'Ile _ . J [j FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO CASH 1 13-24 iREV.1/N 51j �'•'_1�5 '} �'i 14.215 70