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L � � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 6. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6. (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. �- �-.L �r Job Address t,=—�� c>-� I t` 40 city -1] f4C� Lot Size PM L Owner's Name 1. ) kQ7.1" 7 j� Address Fi k 3 LOD ,)ST" C 943 Com, Phone Contractors Name - License No. a� E Phone _ T L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE LFOUNDATION 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 ❑ Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout W ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 1}J LRepair Work Done ❑ Type of Pump H.P. State Work Done Ln Well Destruction ❑ Well Diameter Sealing Material(top 501 O Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION W DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence jo�' Commercial_ Other Number of living units:I Number of bedrooms D LCharacter of sol to a depth of 3 feet: Water table depth .� SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments A PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LLEACHING LINE 0-- No. & Length of linesj L4 0 -r z y X j n To�al length/size FILTER BED ❑ Distance to nearest: 41 I�C)t Foundation r7-�/ Property Line :7-__ LSEEPAGE PITS ❑ Depth Number ' SUMPS W�'Distance to nearest: Well 1674 } Foundation__ _ Property Line 7 r DISPOSAL PONDS ❑ jI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and L. 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." Contractors hiring or subcontracting 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 for all req inspections- Complete drawing on reverse sidee- l/J p1p Signed X 'A'k.f,Y! `� Title: fd"�l ffN 1 Date: // —� /Wc� FOR DEPARTMENT USE ONLY ? Application Accepted by //�"/� Date `' " z Area p g LPit or Grout Inspection by Date Final Inspection by Date if r Additional Comments: L ❑Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 11Tracy 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 RECENED BY DATE PERMIT NO. 1 EH13N Ifl EV.ID/831 ?w-o Cl - - Y"