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II APPLICATION FOR PERMIT 4 , SAN JOAQUIN LOCAL HEALTH DISTRICT ` r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,:TM,i -(Complete in Triplicate) I 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 S-a/n Joaquin t Local Health District. '1S/N� /( �L✓ G�/�e� 6 11: `4 1 Job Address .S �� 2P City Lot Size _-- S PM Owner's.Name Address eJT '7_ Phone r Contractor 1 Ss. t , `7 y`�fFl7 nf�I,��lp1��_. License No�3�OU �C�.`7! Phone TYPE OF WELL/PUMP:_ NEW WELL Iq WELL REPLACEMENT ❑ A DESTRUCTION ❑ j PUMP iNSTALLATION,k SYSTEM REPAIR ❑ i OTHER ❑ DISTANCE TO NEAREST: SEPTICaTANK N DISPOSAL FLD12,OLJI PROP. LINE /�f SEWER LINES �(1/3ii ' FOUNDATION Q �— AGRICULTURE WELL'>�� OTHER WELLnJ� PITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA" ..CONSTRUCTION SPECIFICATIONS ❑Industrial ❑ Open`Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing s- f114 Domestic/Private Gravel Pack ❑ Tracy Type of Casing -S7(�A Specifications 4 '' r ❑ Public ❑ Other I❑ Delta Depth of Grout Seal .��.) Type of Grout I ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by ` I Repair Work Done ❑ Type of Pump H.P. State"Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material (Below 501 - ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.► F, Installation will serve: Residence_ Commercial_ Othed Number of living units: Number of bedrooms f�J +-r Character of soil to a depth;of 3 feet: i - Water table depth r , SEPTIC TANK ❑ ;Type/Mfg Capacity—r No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Well LFoundation— `Property-Line n LEACHING LINE ❑ No. & Length of lines r Total length/size FILTER BED ❑ -Distance to nearest: Well Foundation Property Line II F• Y SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ u 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, I shall employ persons subject to workman's compens_a- tion laws of California." !! The applicantifSiust call for a lll/rree�gbired"ins actions. Complete drawing on reverse side. /� Signed X /I Title: L 5�, /!� f i Date: FOR DEPARTMENT USE ONLY I Application Accepted byDate `?6' Area Pit or Grout Inspection by Date� i 6 '"" Final Inspection by ' - -�� Date -Additional Comments:. !.'� r �d C✓ 6 c 4.,"h�.1 C �+[�f v��. ✓� Q� 5 r✓�L'-To ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Raturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE /- PERMIT*NO. ~� + EH 13-24MEY:I1851 ! OE.0 1751 Jai '7-►!�Ff� S�p,""'i 7 a EH 1428 118 , I