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�- APPLICATION FOR PERMIT 2 U SAN JOAQUIN LOCAL HEALTH DISTRICT A f 1 1601 E. HAZELTON�AVE.,�STOCKTON, CA �1 YV 1 Cz V 1 Telephone 12091 466-6* PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" i /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. 1� 3 " , j , t .R; F �• . (ice Q 1 f Job Address 22 �p,+/J .` ' `f '' City }Lot Size PM Owner's Name = Address 2226 k5 WAIDON hone -1-5147^ZF Q Contractor Address B" L`fEense No. aC&8/3 Phone TYPE OF WELL/PUMP: 17NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �S'/ SEWER LINES DISPOSAL FLD. '75'S't PROP. LINE "l -FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4t Dia. of Well Casing 1 X Domestic/Private X Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION.0 REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity i No. Compartments PKG. TREATMENT PLT. ❑ E - ` 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 Foundations .Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well p Foundation ' j— Property Line i DISPOSAL-PONDS— ❑. _r _ _e. .. __, i- r, �-...- �� ,�- .: _-. t 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 s 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 appli must gall for all quired ' spectio . C plete drawing on re arse d i r E, Signed itDate: FOR DEPARTMENT USE ONLY _`, Application Accepted by Date Pit or Grout Inspection by Date d— Final Inspection by :- ` 1M Date'T U Z4_J Additional Comments: E�! II ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201'__' ' rte,, i` p FEE A INFO AMOUNT DUE AMOUNT REMITTED ZASIARECEIVED BY DATE """ -�.PERMITN0-" {: + EH 13-24(REV.1I a 5) I:H 14-26 E