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� APPLICATION FOR PERMIT � ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 CMZ PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) �T 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.599 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /17505d � Job Address 73005, / �fJ j City� t1v ,__ Lot Size PM Owner's Name 5T4Al =!V/" Address ..41). /gaxt-_ :7,11, 4= Phone ,t' y U/X 7TH Contractor /� ey)e)wlyJ S ::R&Address ,2r�ap License No. �o � Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR C1 OTHER ID DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "�— DISPOSAL FLD.--� PROP. LINE FOUNDATION Z5 If- AGRICULTURE WELL , OTHER WE4L PITS/SUMPS S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, i /f ❑ Industrial ❑.nOpen Bottom ❑ Manteca Dia. of Well Excavation 1- — Dia: of Well CasingG� / AvOomestic/Private XGravel Pack ❑ Tracy Type of Casing Jv Specifications FI Public n 0O1tt/er 171 Delta Depth of Grout Seal Type of Grout � 1 I Irrigation 9LApprox. Depth �Eaassttern Surface Seal Installed Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth Filler Material (Below 501 -J TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (NO septic--ssy�sstem permitted if public sewer is �J available within 200 feet.) 0 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 No. Compartments PKG. TJ3EATMENi-4Li:4- --'---'---"— ---- ---------- Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE_. ❑�--No.•& Length of linesTotal length/size FILTER BED ❑ Distance to nearest: Well _ ' Foundation` ----Property Line' SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest:. Well Foundation Property Line DISPOSAL PONDS ❑ / -- -- – - -- I hereby certify that I have prepared this application and that the wor will be dond`io e6corclance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner orilicensed 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 nanner asto became subject to workman's compensation laws of California." Contractors 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." '-�A The applicant r II tpq ions. Complete drawing on raver 4)de. L_ ./e�N�� _ __._._�.__ Signed X �/ — Title: ../ +�'�'�• Date: p \ FOR DEPARTMENT USE ONLY r t Application Accepted by Date AZ I—f2 Area aS Pit or Grout Inspection by Date -rFinal Inspection by Date -a-- Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7109 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8V DAT PERMIT NO. INFO /� • EH 1b241REV.11rte) EH 14-te