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• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT pAG�IV E� 1601 E. HAZELTON AVE., STOCKTON, CA RE Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) EN1A� HFA�TH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heragsR ROA%F�iv�W� ton 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 /"/� 10 ) �/ Q �lzy O�'? / City �� Q'7 Lot Size `ze Q PM Owner's Name 'V//17D/011/ 40�/ C.O. Address /��• �( /. /I/ ?n, es6phone(Z� S� �Z�/ Contractor LOIJ/'�'/,� ,`X;41f✓ Address VA 333-700 Z�'{�-9703 License No. Phone 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ r. Specifications FI Public ❑ Other fl Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State\kork Done _ Well Destruction ❑ Well Diameter _ Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms ICharacter of soil to a depth of 3 feet: —__ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines _- __. Total length/size FILTER BED Ll Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS 1 1 Depth __— _Size Number SUMPS LI Distance to nearest: Well Foundation Property Line _— DISPOSAL PONDS Cl 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 compensa- tion laws of California." The applicant st call.for all eq ui ed inspections. Complete drawing on verse side. 1y Signed X IT/' —--- Title: [l� ------ Date: 1 J a FOR DEPARTMENT USE ONLY C Application Accepted by �� L (/ Date Area J Pit or Grout Inspection bey,? _ Date _. Final Inspection by Date Additional Comments:,% ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 AppliEant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk./CA 95201 INFO FEE AMOUNT DUE AMOUNT REMIT-TED CK RECEIVED BY / DATE PERMIT NO. a EH 1 3-24(REV.i/m 51 3S. L� 3� (z) 7�Q �� EH 1128 V V U