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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -* 1601 E. HAZELTON AVE., STOCKTON, CA X/1! 012 Telephone'(209) 466-6781 PERMIT EXPIRES,1 YEAR FROM DATE ISSUED (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 Sari Joaquin Local Health District. Ur � Dj Job Address -q7/�/`7 �� 1 �� City Lot Size _� i ` PM Owner's Na �- FJ�� l^ Contractor Gf!-� t/ yV��/ sIr � 0� �H/�G Lice e No�3S�4P/-f.� Phone.�4�'A�7� VICAddress TYPE OF WELL/PUMP: NEW WELL f!- WELL REPLACEMENT ❑ DESTRUCTION ❑ \ PUMP INSTALLATION p7 SYSTEM REPAIR ❑ OTHER ❑ 'I DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES eAJ��IT,J �.._�— DISPOSAL FLDArf(J� PROP. LINE�S59 FOUNDATION ✓ r AGRICULTURE WELUV_ ,�� OTHER WEL �_� PITS/SUMPS! v N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing o,6omestic/Private• ❑ Gravel Pack ❑ Tracy Type of Casing • Specifications F] Public ❑ Other C i Delta Depth of Grout Seal Type of Groutl'I_�f G'� i I 1 Irrigation. Jy -Approx. Depth l Eastern Surface.Seal,Installed by L � �� r - ""ftepair Work Done ❑ 'Type of'Pump H.P. ! r• ` State Work Done ry1 Well Destruction ❑ Well Diameter Sealing Material (top 50 ti Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION Ll DESTRUCTION 1 1 (No septic sys*m permitted if public sewer is k' �`�r== ►a. :available within 200,teet.) 4 Installation will serve: Residence_ Commercial'— Other - p ' Number of living units: Number of bedrooms ,_^:._ Character of soil to a depth of 3 feet: Water table depth tJ SEPTIC TANK ❑ Type/Mfg -Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Foundation Distance to nearest: Well FoundatioA 'Property Eine F LEACHING LINE' _ ❑ No. & Length of lines . Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE"PITS I'] Depth Size, Number i SUMPS 1-1 Distance to'nearesC Well Foundation Property Line I 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., r t r . 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 n employ any parson in such manner as to become subject Co workman's compensation laws of California.-" Contractor's hiring or sub-contraraing signatur 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." f The applicant must call for all required inspections. Complete drawing on reverse side. �y -y G �i Signed X lam' Title,: l_� Date: �r FOR DEPARTMENT USE ONLY l Application Accepted by Date Area j, Pit or Grout Inspection by _Date Final Inspection by Date Additionai Comments: ❑ Stk 466-6781 ❑ 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 96201 f, FEEAMOUNT DUE AMOUNT REMITTED: C SH RECEIVED BY DATE PERMIT NO. INFO_ - `' ld ..�p.S' a EH 13-24(REV.I/x 51 EH 14-26