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� APPLICATION FOR PERMIT 7- 1 &"� SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL i ON AVE., STOCKTON, CA b'e �� f4Id Telephone (209) 466-6781 r -�' -�v PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I �4S-vu r wr. (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.649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address O T / city STI{',(/ Lot sire PM Owner's Name Address Phone?�/�� '�jl�///`l� Phone a �f,07V ? I Contractor�Qf/ Address�1.f2 //� / QXLicense No. -&alvzl._Phone TYPE OF WELL/PUMP: NEW WELL J WELL REPLACEMENT 171 DESTRUCTION PUMP INSTALLATION ❑ )611 SYSTEM REPAIR U OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ___ SEWER LINES _- DISPOSAL FLO._ PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL_ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^} U Industrial C Open Bottom ❑ Manteca Dia. of Weill Excavation Dia. of Well Casing Domestic/Private C Gravel Pack G Tracy Type of Casing__ Specifications 17- Public ❑ Other C Delta Depth of Grout Seal Type of Grout I] Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 4 Repair Work Done J Type of Pump H.P. State Work Done 1� - Well Destruction V Well Diameter Sealing Material (top 501 S Depth _ Filler Material (Below 50') _ TYPE OF-SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ DESTRUCTION U (No septic system permitted if public sewer is available within 200•feetr)--,� Installation will serve:-ResidenceCommercial_Other_ -�-�- - ---- -ice Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _Water table depth SEPTIC TANK -7 Type/Mfg _ Capacity_ No. Compartments PKG. TREATMENT PLT. J Method of Disposal Distance to nearest: Well Foundation Property Line _ LEACHING LINE ❑ No. & Length of lines Total length/size ' ,.;LA , a FILTER BED ..��--Dist ance.to nearest: Well Foundation_ Pioperty Line SEEPAGE PITS D Depth __Size Number. aY�� ^`J SUMPS Distance to nearest: Well_ Foundation _ Property Line DISPOSAL PONDS ❑ �_ _ e 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, 1 shall not j employ any person in-such manner-as-to become-subject to workman's compensation iaws,of-Calfornia."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." . -Vy'k=, ` The applicant m c _a required ' tions. Complete drawing on r �ide./i/9i�i%fQ-t�lflL- D r� Signed X _ _ _, Title: 1 _ Date: c7 / t Dq e• FOR DEPARTMENT USE ONLY i Application Accepted by _ ��^`�'� Date �� ^�- Area Pit or Grout Inspectio by Date Final Inspection by [� �L Date yo r Additional Comments: ❑ Stk 466.6781 C' 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., CA 95201 • INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. t +EH 132 (REV.1 5 Zu�� EN 14-26