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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 f {L` City Lot Size PM Owner's Name �4Ll Address �r /�7�- � /T C71 --. --- Phone� G f Contractor 5 Z +'CSC /F(Address IY � C JCI cense No. +1 7 Phone,,M 3'3 9 TYPE OF WELL PUMP- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR U�1, 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 CONSTRUCTIOWSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack Ll Tracy Type of Casing_ Specifications i-1 Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout _ Irrigation _..Approx. Depth 1•I Eastern `Surface Seal Installed by Repair Work Done L7 Type of PumpR�t?i t N H-P. _____ State Work Done 1 j 1, Well Destruction ❑ Well DiameterSealing Material (top 50'1 n t.4; C li 1j 4 U $ T}l1t rJ Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RFPAM1ADDtTION l I DESTRUCTION t I (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 No..Compartments PKG. TREATMENT PLT. ❑ Methol .�- Distance to nearest: Well Foundation s Property Line LEACHING LINE ❑ No. & Length of lines Total length/size2 2 112R2 FILTER BED ❑ Distance to nearest: Well. Foundation PropertLine 1!1(.jTY �AN i` M- r, 444 ` L l+ SEEPAGE PITS I I Depth Size _ Number nn,exrr. "51L; F t:i r14�`i,j'l CNV SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, Arid rules and regulations of the San Joaquin Local Health District- ! Home owner or licensed agent's signature certifies the followipg: "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." 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." The applicant must call all required inspections. Complete drawing on reverse side. ` Signed X - Title: 2 Date: l G" `cl�___ FOR DEPARTMENT USE Oi LY y Application Accepted by Date y��? 'Z— Area-_ �` 17�� Pit or Grout Inspection by Date Final Inspection by ^ z / ' Date Z Additional Comments: ID Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 8,23-7104 ❑ Tracy 835-6385 . Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY yJ DATE /PERMIT'NO. +.EH 13-24IREV-i/N5] �L. L r f fe.?/ L / G. EH 14-28 JJ 1 _-tl/G �iS� ri 1� /) -