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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 41:6-6781 PERMIT EXPIRES 1 YEAR FROM DATE !SSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/o,install the work herein described.This apdicauon 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. Jots Address �7r ��T Ulf.F-,5 City Size PM— Owner's Nama��G��Fc��-� �Zddress _31'Z, AYJ Phone � 'Acx� Contractor Z2 r! Y7 ��S ___SC LS ddress,�rf6 /�2YC4'�—'icense No. Pho^e ZC��,C' TYPE OF WELL/PUMP NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR I-] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public ❑Other D. Deita Depth of Grout Seal Type of Grout -- D Irrigation ---Approx. Depth U Eastern Surface Seal Installed by Repair Work Done _. Type of Pump H.P._ _ State Work Done Well Destruction El Well Diameter Sealing Material(top 50'1 - Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION G REPAIR/AODITION DESTRUCTION L] (No septticlable systemithin feettted If public sewer is Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms _ �'G� Water table depth_S�-' -haracter of soil to a depth of 3 feet: - -' SEPTIC TANK C Type/Mfg Cdpacity_ No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line_ LEACHING LINE ❑ No. ,Length of lines 1__ U Total length/siza— FILTER BED ❑ Distance to nearest: Wel! Foundation — Property Line L Size__ r' Number SEEPAGE PITS Depth ! SUMPS 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 accordance with San Joaquin county ordinances,state laws, and ilas and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following "I certify that it 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 e certifies the following:"I certify that in the performance of the work for which this permit is issued,I fKgll employ persons subject to workman's compensa- tion laws of California." The applicant must call forequired inspecti�,,is. uumplete drawing on reversa side. Title:.-!'- .cam-- — Date: �._� Igned X_ FOR UbtARTMEN,,-USE ONLY ` /\ �T.cr Date_ �� 0 Areay 2— Application Accepted by -- � Date''_/_—L Final Inspection t-- Dat 0 7 Pit pr Grout Inspection b 4 t✓rt u 1 6 e r4 ✓e tf c:/✓e ��/ �'2 I' `'e v Additional Comments: C Y 3 ��v--�5 ' �—�` o/r y c J Stk 466-6781 Lodi 369-3621 Manteca 823-7104 L] Tracy �� r4r. j' �e �t-r J Q Applicant- Retum all copies to: Environmental Health Pormit/Services 1601 E. Hazelton Ave., P.O. �0 2p08�tk" r-e-,(T r!N^ek7 FEE AMOUNT REMITTED CK s RECEIVED BY DATE PERMIT NO. AMOUNT DUE CASH INFO EM 13.24 IREV. 00 FH 1..2a