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j t u APPLICATION FOR PERMIT SAN JOAQUIN LOCAL WEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA_ ' Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DAVE 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 mado in compliance with San Joaquin County Ordinance No.1549 for sawago or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _ n�^__ City_1 Lot Size CiIS l � PM Owner's Name \I ryl Address A• C1 �7n t '1iYI� _ Phone 6 -OW-33 �Conlractor T_Y_PE OF WELL/PUh1P: NEW WELL ❑ WEU.REPLACEMENT ❑ DESTRUCTION [7 PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ___ DISPOSAL FLD.____ PROP. LINE FOUNDATION AGRICULTURE WELI. OTHER WELI. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation____ Ola. of Well Casing _ IJ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications 1'1 Public n Other F1 Delta Depth of Grout Seal Typo of Grout v I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. Stale Work Done__... r Well Destruction ❑ ,Well Diameter -__ Sealing Material flop 50') `�� Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLA7tON REPAIR/ADDITION I 1 DESTRUCTION 1 I (No septic system permitted if puhlic sawer is available within 200 feet.) Installation will serve: Residence `P 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 Cc y�t�b Capacity <? No, Compartments PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well, Foundation__.Property Line LEACHING LINE ( No.& Length of linos _. Total fength/size FILTER BED O Distance to nearest: Well !x-41— Foundation 30? Property Line r __ SEEPAGE PITS I i Depth Size_ _ Number yf SUMPS 1_1 Distance to nearest: Well _ Foundation _ Property Line _ DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordanco 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 unifies the following:"1 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 porformance of the work for whlch this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applican t c or all required inspections. Complete drawing on reverse side. Y11-Signod _ Title:_- ,�5 1 rs� __ -7 b ��"�'^ Date: _ G'�-0 (("�` FOR EPARTMENT USE ONLY Application Accepted byGu,. Date _ Area � _- Pit or Grout Inspection by __ Date Final InspocCon b Oate� // Additional Comments: �ai6 P�� ihu /?bY�C LfcL�-qH Q�" c ctr^fir Cl Stk 466.6781 17 Lodi 363.3621 1-1 Manteca 823-7104 O Tracy 835-6385 Applicant. Return all copies to: Environmental Health Parmlt/Services 1601 E. Hazalton Ave., P,O. Box 2009, Stk., CA 95201 IYFO AMOUNT DUE AMOUNT REMITTED CASHfZIV/E/O/�9Y DATE PERtd1T'fd0...EH 13.24rnEV.tlaSlZ �� EH 14h3 L/