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' ¢ -V APPLICATION FOR PERMIT f SAN JOAQUIN. LOCAL HEALTH DISTRICT 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. Job Address ��` 5 o ,y,4v Q-- City G Lot Size PM .Owner's Name 1jel { Address Phone Contractor's Name •� If ZI 1"lJ/G E4- License No. ,_2,- 2 Phone =T TYPE:OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL,FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL} PROBLEM AREA CONSTRUCTION SPECIFICATIONS;'',_ ❑ Industrial ❑ Open Bottom x ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other j ❑ Delta Depth of Grout Seal Type of Grout r ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t Repair.Work Done 'f❑ Typeof Pump ` H.P. State Work Done Well Destruction 0 Well Diimeter Sealing Material (top 50') Depth i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION;K DESTRUCTION ❑ (No septic system permitted if public sewer is n� In allot n-will serve: Residence Commercial Other available__within.200_feet.1. F Number of living`units'� Number of bedrooms , Charactet of'soil to a depth of 3 feet:• Water table depth i SEPTIC TANK" Type/Mfg{ Capacity No. Compartments PKG. TREATMENT PLT. Cl- i �. * Method of Disposal Distance to nearest: Well Foundation 7 f Property Lined r LEACHING LINE -❑---No_,& Length of lines "` Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line s Ij[t SEEPAGE PITS J``,. _ ;❑_�Depth y; �-- Size y'� Number SUMPS 4 ❑ Distance to nearesti-�w-Well ,Foundation Property Line DISPOSAL PONDS -..�r❑,r 1 hereby certify that I'haveprepared'th'is applibetion and'Wat.the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of,the-�Sa'i 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."'Contractors hiring or sub-contracting signature ' certifies the following: "I certify that in the performance of the work,.for which this perm is issued, I shall employ persons subject to workman's compensa- tion laws of California." j The applicant must call for all quire sppeec�tions. Complete drawing on reverse side. Signed '4.Title:. "-Arz .t i . -- - Date:' ' OR DEPARTMENT USE ONLY �� .• +Ji I Application Accepted by Date Z 0E Area GJ r Pit or Grout Inspection by Date Final Inspection by Date ✓=a/f 7- Additional Additional Comments: ❑ StO 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy; 835-6385 k Applicant= Return-all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box-@ ;Stk.,CA 95201— INFO MOUNT DUE AMOUNT REMITTED CASH~/ RECEIVED BY DATE PERMIT N0. + EH1324 PREY.101831 y Q ��IV8� ji_�LA g i t H 14-28