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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT ,. 1601 E. HAZE T ON AVE., STOCKTON, CA -� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y, 7. (Complete in Triplicate) `4 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 .e F 2,0z7 Alo b --P __._ City ,�106L Lot Size A0—09-C,4-4S-- PM Owner's Name 10t" VA�---_-_��LZ/�L ' Address �fJ. l.3327 M�D� --- Phone 9.S3.S.3 S 1-11T, j } Contract or i_A1�1S c, L-, y icense No., yAddress�C). IgS�O _ S+km 254��3_-Phone — ` TYPE OF WELL/PUMP: tNEW WELL'❑`--�--• _._:WELL REPLACEMENT E1,.: DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR❑----.__ -- -OTHER O DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES.- DISPOSAL FLD. �PftOP:-L-±+ FOUNDATION_— �`AGRICUCTURE-WELL � --- OTHER WELL--! PITS/SUMPS �~ INTENDED USE �-- TYPE OF WELL PROBLEAREA—CONSTRUCTION SPECIFICATIONS ( 9-Industrial ❑--Open�Bottom [7 Manteca Dia. of Well Excavation---- •- Dia.,of Well Casing O Domestic/Prrvate'�"6 O Gravel Pack O Tracy Type of Casing Specifications�4 ❑ Public ❑ Other I I I Delta Depth of Grout Seal _._ Type of Grout _— �=' C Irrigation --Approx. Depth ❑ Eastern Surface Seal Insta{led by, �- Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter _ _._ Sealing Material (top 501 I Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ■ DESTRUCTION O (No septic system permitted if public sewer is -1 available within 200 feet.) Installation will serve: Residence Commercial — Other �NLM/r5T/11AG — - Number of living units: — Number of bedrooms _ Character of soil to a depth of 3 feet: SANDY LO hn _._ Water tab) depth — SEPTIC TANK 0 Type/Mfg CONC !L 12t21SH Capacity -gA00 No. Com_ partments -- PKG. TREATMENT PLT. ❑ r * Disposal�al — Method-of Distance to nearest: Welt LOO_.— Foundation-14—PO Property Line'��00 t `_ LEACHING LINE O No. &Length of lines - Total length/size �f X 70�=.2/ZQ / E FILTER BED ■ Distance to nearest: Well 100* Foundation &c)' * Property Line 1100 SEEPAGE PITS ❑ Depth i Size Number SUMPS ❑ Distance to nearest: Well _..._ Foundation DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ani 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 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 r I 1 The applicant must call for all required inspections. Complete drawing on reverse side. ' I ( 1 t Signed Title: Date: FOR DEPARTMENT USE ONLY �� /O Application Accepted by __ __ Date Area i � I Pit or Grout Inspection by Date Final Inspection by _ _ ate Additional Comments: •� ! 1 I I 1 1� O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95201 11 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY �) DATE ,PERM17'N0. INFO CASH + EH 13-24(REV.ii a 5) EH 14-28 --