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4 7 APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT i6ol E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '- (Complete in Triplicatel Application is he.eby 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 cempiiance with San Joaquin County Ordinance No.549 for sewage or No.1852 for well/pump and the Rules and Regulations of the San Joaquin Y Local HeaVth District. /_ L5 - Job Address � ," e CityS� Lot Size 4i�f PM p _ /�,1�4i Sal n _Phone Owner's Name —F F �rri✓ Address �.. } Contractor 'x Address - �License Nod _ Phone - TYPE OF WELLlPUMP: 4 EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ e PUMP INSTALLATION 8( SYSTEM REPAkR D OTHER ❑ Mi DISTANCE TO NEAREST: SEPTIC TANK JV SEWER LINES &.QDISPOSAL FLD. PROP,LINE C� YI _ FOUNDATION SA' AGRICULTURE WELL OTHER WELL &T' PITS/SUMPS i INTENDED USE TVPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation 4;2 it Dia.of Well Casing r I p.Q Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing Eji�ir— Specifications FI Public ❑Other ❑Delta Depth of Grout Seal �-, 'ro Type of Grout Q. Fr I I Irrigation _..Appx.Depth I I Eastern Surface Saul Installed by ..--Q � �j Repair Work Done L1 Type of Pump h H.P. rState Work Done s Welt Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Material l8elcw 50 _ TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIRIADDILON I I DESTRUCTION I I (No septic system permitted if public sewer is `- available within 200 feet.) Installation will serve: Residence_ Commercial Other- Number of living units: - Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments PKG.TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.&Length of lines Total length/size J — FILTER BED ❑ Distance to nearest: Well Foundation Property Line r ` SEEPAGE PITS i I Depth Size Number 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 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 Fir employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 1 f certifies the following:"I cerffy that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tL tion laws of California." The applicant must all or require - ions.Complete drawing on reverse side. Signed X Title: 0", Date: FOR DEPARTMENT USE ONLY 41Z g-7 i [V Application Accepted byDate Area 7 7. + -- Pit or Grout Inspection by Datei/�� d Final Inspection by 1 Dale ! ✓ I Wa �. Additional Comments: � r - � 7'r .� }}}... L1Stk 466-6701 ❑Lodi -3621 b Mamaca 823-7106 D Tracy 835-6385 ! Applicant-Return all copies to:Environmental Health Permit/Serviees 1601 E.Hazelton Ave.,P.O.Box 2009,Stk.,CA 95201 - VqRA r INFO AMOUNT DUE AMOUNT REMITTED G RECEIVED BY DATE PERMIT NO. t��f tnev. ray Ic S77 Eh as-24 1 ��r�a /zit Fr 9-7-3 0 F .� Fi Fir F � r 1/