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APPLICATiC.N FOR PERMIT *AN JOAQUIN LOCAL HEALTH DIST 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. J^ -TE 1> A/c" 909 6 /4f-IR 0mgtk) fn' City rSl�%l4� Lot Size PM Job Address, , Owner's Name �� V�t+ I)f V!; 17-:: Address Ic/Ur�, �Lxl 0-2 6>1,L Phone^O h/'iUV,/T455 Gh/Ery'1CRLCGo. _r =U 1AtIVCHC) CCQNN lln � Contractor ,/sl«:. /7//9`Z;1,<t4 T' Address3MgtT ^ALh License No. !: ` 7q— Phone F''6 `'cJ— /L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK >I CK2 SEWER LINES >I Op DISPOSAL FLO. 71 CC) PROP. LINE >I FOUNDATION �` (!1� AGRICULTURE WELL71� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of�P-Er<EePatfbn fh ff Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of astng Specifications I� f l Public '14 Other TG3', i4/%tfl Delta Depth of Grout Seal Type of Grout� T I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - •� Repair Work Done ❑T�Fype of rPumpW ATE�-- H.P. State Work Done_ oC Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 (\( TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth N SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments S PKG. TREATMENT PLT. ❑ Method of 5 Disposal Distance to nearest: Well Foundation Property Line r'.�vV�M 2 ZECE: u.'IrID 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line' t SAN .iOA.^.•l Ili•.j :,;; r .: .;,..,/ SEEPAGE PITS I I Depth Size Number Pili't.Lil, SUMPS L1 Distance to nearest: Well Foundation Propbfry Mite 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tiorl laws of California." The applicaTri�must call mall required inspections. Complete drawing on reverse side. Signed X�r Title: /��-OLC7/�•r�I Date: /t 4/4617- =Date FOR DEPARTMENT USE ONLY Application Accepted by " IDate AreaPit or Grout Inspection by �7L Final Inspection by C� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., V FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVE eY OATE PERMITNO. INFO /J IT CASH • EH 1}24(REV.tin 51 EH 1426 VV V