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I APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 1 Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y `" ip,l. . _ P (Complete in Triplicate). i 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. Job AddressRa°iceeon 90 E6 i w City. Lot 5 - - _ 55 PM � + Owner's Name (v Address.042��.Q:�(� J 4- 11 t t h Phone Contractor Address License No. s TYPE OF WELL-/PUMP: Phone NEW WELL ❑ WELL REPLACEMENT ❑ - .... DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ _ { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES l\F_OUNDATION DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial :❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type Of Well Casing °►�" ype of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ IrrigationType df-Grout _Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing'Material {top 5011' Depth I Filler Material (Below 50') r� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence Commercial, Other vailable within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet `;., SEPTIC TANK ❑ Type/Mfg Water table depth � Capacity No. Compartments PKG. TREATMENT PLT. ❑ � _ J Method of Disposal j I Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No.'& Length of lines ` s E t Total length/size FILTER BED " ❑ Distance!to nearest: -t-Well Foundation II Property Line SEEPAGE PITS EJDepth .ifi Size SUMPS Number }• ❑.. Distance to nearest: 11 Well Foundation Property Line �^ DISPOSAL PONDS ❑ I hereby certify that! 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." i The applica must c I for all re -red cfions. Complete drawing on reverse side. ;D x Signed Xr Title: / p r Date: _ /^ O FOR DEPARTMENT USE ONLY Application Accepted by '! Date f Area LJ Pit or Grout Ins Y { pection by Date Final Inspection by 1Date Additional Comments: �l/Gr'G CE ? �. (� 90 i��3 93• e�iYJ/ (fp LI /d Stk 466-6781 1i Lodi 369-3621 ❑ anteca 823-7104- . ...13 Tracy 835-6385 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA,95201 FEE , INFO AMOUNT DUE E;AMOjUNTEMITTEDM[171- RECEIVEDDATE PERMIT NO. + EH 1428IR£V �� a