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�i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E. HAZELTION ON AVE., STOCKTON, CA 1601E ' Teiephohe (2091 466-6781 �I f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) V it nd/or instal[the work herein described. This application is Application is hereby made to the San Joaquin Local Health District for a permit to construct a It) and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No'549 for sewage or No. 1862 for we Local Health District. I! #: _. �t t�r t 1`'�4 I I�I LLJ. . vile> Da WC City Lot Size QPM } Job Address IkZ S5�3 t�D iqe-L5C-W rV1 (�1 2rj C o f-r5c�ci Phone Zc9 4&r`.—CO Owner's Name V C Address - Ck 0S�3 31 14 - 1 Contractor l✓�t ee?-r H Address ��11 IS I 1tflk�i (cense t,,L5 �ZC3G'- Phone 5�j�' TYPE OF WELL/PUMP: NEW WELL ❑ i WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER I'�G1 (10141� DISTANCE TO NEAREST: SEPTIC TANK >100 SEWER LINES 2 Sb - DISPOSAL FLD. PROP. LINE FOUNDATION >ICO 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 Eo:Gravel Pack ❑ Tracy Type of Casing r' ��L Specifications 1': Cetytt;c `�rT Type of Grout — ❑ Public Cl,�Other n Delta Depth of Grout Seal 1� r __ I ! Irrigation L�Apprax. Depth I I'Eastern Surface Seal Installed by r Repair Work Done 0 Type of Pump ! H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material IBelow 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITtON 1 ! DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms l� Character of soil to a depth of 3 feet: 1! Water table depth ' SEPTIC TANK ❑ Type/Mfg ii Capacity No. Compartments PKG. TREATMENT PLT. ❑ 11 Method of Disposal Distance to nearest: Wiell . Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. A 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant Wst call for all r aired in ction$. Complete drawing on reverse side. f IS �� 1�tr T374 Date: Signed X. _ Title: _ FOR DEPARTMENT USE ONLY ti Application Accepted by Date Area r o Pit or Grout Inspection by ate Final Inspection by c Date�'a� r 4 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant- Return all copies to: Environmental Health Pt.rmitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 G iL J FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. INFO Q� ��/�(,� �[[�\ +i « EH 1124IREV.Iiwsi �"f �+• p-/ i ` EH 1428