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APPLICATION FOR PERMIT yr SAN JOAQUIN LOCAL HEALTH DISTRICT ��U° ' �&aer 1601 E. HAZE LTON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM. DATE ISSUED (Complete in Triplibate) Application is hereby made to the San Joaquin Local Health District fora 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. 16U for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r.. ; I I Job Address O.._ •��/ S E� ,� - city t I _. '77C.tJ Lot Size PM 4 Y Owner's Name g__ -So,elSAddress� -E i S Phone Contractor F" D AJ400 Address 1pox' & L I c.c i,g& ,e y9 License No. IV2��71� ,Phone #&X"Z 7/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C fON ❑ PUMP INSTALLATION ❑ SYSTEMI REPAIR El.i OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ��l INTENDED USE TYPE OF WELL PROBLEMAREACONSTRUCTION SPECIFICATIONS 1 �•S 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I �� Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack i I Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --L4pprox. Depth ❑ Eastern Surface Seal Installed by 1 ---rd Repair Work Done ❑ Type of Pump H.P. !� State Work Dane f Well Destruction ❑ Well Diameter Sealing Material (top 50') ; Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW I�NfSTALLATION ❑ (REPAIR/ADDITION ❑ DES i RUC N j$(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceCommercial Other Number of living units:_.._L Number of bedrooms I•. I Character of soil fto a depth of 3 feet: b. ' ^^� } Water table,de th SEPTIC TANK ' " C] T e/Mf ► p + g Capacity No. Compartments I' PKG. TREATMENT PLT. ❑ t ' �'f �I }� Method of pisposal � Distance to nearest: $ Well Foundation Ii # Property Line ) 1 LEACHING LINE/ ❑ No. & Length of lines3 Total length/size .. FILTER BED ❑ Distance to nearest: Well Foundatioril 4 Property Line SEEPAGE PITS ❑ Depth 1 Size Number I �� SUMPS . ❑ Distance to nearest: 2 Well Foundation `( Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in'raccordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I! 6 Home owner or licensed agent's signature certifies the following: I certify + la an " r�Y that in the performance of the work for which this permit is issued, I shall not em p y y 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 compensa- tion laws of California." - The applicant must call for all required inspection " mplete draw`ing qn reverse side: '=_ - aL , Signed �. �� _ Title: Date: t R PAfIT NT USE ONLY Application Accepted by c !1 Date -3� Area Pit or Grout Inspection by. Date Final Inspection by Date Additional Comments: / / � �3:? ❑ Stk 466-6781 ❑ Lodi 369 f ❑ Manteca 823-7104 ❑ Tracy 1.835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltoh Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK 10 INFO CASH `RECEIVED BY DATE E?;7— IT NO. + EH 1428(REV.1/0 [� EI J F