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`I APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT I ^9 1601 E. HAZE; TON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) NVIGt% l . AL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereinis 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. f/ Job Address/ _ _- L/J F J'- City o-'- Lot Size PM :a Owner's Name ✓ ` i Address�-i'��.{/�� 1 Phone { �� .ContractorAddresi Ir, (3'��'7 f q1 �,�License No(_G 3 7 j, Phone TYPE OF WELL/PUMP: NEW WE�L,❑1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.[B' 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 ❑ Domestic/Private ❑ Gravel-Pack ❑ Tracy Type of Casing Specifications M Public C1 Other C] Delta Depth of Grout Seal Type of Grout I I Irrigation y; _ Approx. Deptth{ I I Eastern - Surface Seal Installed by Repair Work Done 2 Type of Pump H.P. State Work Done I Well Destruction 0 Well Diameter I Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: .NEW INSTALLATION 1.1 REPAIR/ADDITION I i DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re_siderige _ CoRrmercial____-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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED:' ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth _° Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El hereby certify that I have prepared this application a 4d that the work Will oe done in accordance Sain county ordinances, state laws, and rules and regulations of the San Joaquin Local Health�DisVrct — ,cordance with `_.n Joaqu_w Home owner or licensed agent's signature certifies thei,foliowing: "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 k 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." - 1 The applicant st ciol for all required inspections. Complete drawing on reverse side. Signedills: / DatelCe FOR DEPART INT USE ONLY �. iJi # Application Accepted by Date Cz '' Area Pit or Grout Inspection b Date Final.Inspection by I Date 3` Additional Comments; i ❑ Stk 466-6781 ❑ Lodi 36,9-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED. CASH RECEIVED 9Y DATE PERMIT NO. * EH 113 4-241REV.vn51 �/� X, EH 14-2e < �/ — 11