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• i APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT f41 i' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y; (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. Il. Job Address / ![s�\/�CftI� _ A' I: a City s""cot Size *M Owners NameAddress lS i i eQrY�.•/�►YI�w�—c Phone dg7 — Contractor . •Addres� 1C L ZI! License No. Z 7 Phone bZ TYPE-OF -WELL/PUMP:- © .�/ WELL REPLACEMENT _` _ -_`_DES_T_RUCTIO_N ❑ PUMP INSTALLATION Lti� SYSTEM REPAIR TOfHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 1 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 I1 �Public ❑ Other ❑�Delta Depth of Grout Seal Type of Grout �Dation J/ ype Approx. Depth IafEastern S dac SeW Installed by ate I Repair Work Done f7 Tof Pump 1)w.r. H.P. StWork ,'Well Destruction ❑ Welt Diameter' Sealing Material flop 501 - �^ ;Depth '4 Filler Material (Below 501 J TYPE OF SEPTIC WORK: `NEW INSTALLATION 1.1 REPAIR/ADDITION L I DESTRUCTION I I (No'sap(ic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Comm'ercial Other Number o1 livingunits: Number of bedrooms 1 ly. •� .� Character of soil to a depth of 3 feet: _ i - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments /CJ/ PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well uod n Property Line LEACHING LINE EllNd. & Length of Ii s - _Total length/size - - FILTER BED ❑ Distance to naerres : Well Foundation_ ' Property Line _ b SEEPAGE PITS I I Depth '� ize Num SUMPS Ll Distance to neare Well '•"-' Foundationn- 1 'r Pr6pe Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulatio San Joaquin Local Health Datrict. Home owner or need eg is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any s in such nner as trace ject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the ollo ng: "I 'fy at i the rf nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws Cal" r ' n - The app cant at for ctions. a rawtng on rey§JA de. Signed Title: Date: (IFOR DEPARTMENT USE ONLY ('_ Application Accepted by Date G- Application Q�I� Area Pit or Grout Inspection by Date Final Inspection by ` 'wt Date n Additional'Comments: t O Stk 466-6'781i ❑ Lodi. 369_3621 ❑ Manteca 823-7104 ❑ Tracy 835-63.85 _ Applicant - Return all Eopba.to:-f lwiron•1i rental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEf)"•' CA$R _RECEIVED tiV -•� DA7E._. . . PERMIT NO. INFO ..EH 1a.21(i beef pR y5 %- c - 3 EH 142a