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s , APPLICATION FOR PERMIT ; +. SAN JOAQUIN LOCAL HEALTH DISTRICT ^ .. ` 1601 E. HAZE T ON AVE., STOCKTON, CA ; Telephone {209} 466-6781IV ' PERMIT EXPIRES 1 YEAR FROM BATE ISSUED N1'" C' ,9 ��`r� {Complete in Triplicate} *, Z Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.}This a-application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Reg u'iafions oMe San Joaquin 5 Local Health District. E '1 Job Address City Z e i&Q4 r'"-'Lot Size �M a Owner's Name yo Address (hone _ L J �� r Contractor G-(.fi oaf[a flS_Address_{�y�_ �at e_1 ,License No. Phone TYPE OF WELL/PUMP: - NEW WEL-L---❑ WELL' C] ^ DESTRUCTION ❑ PUMP1INSTALLATION ❑ ' 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 ❑ Trac Type of Casing Y YP 9 f � Specifications r Public ❑ Other# ' (-] Delta Depth of Grout Seal r Type of Grout ! ,�if Irrigation .-gpprox. DepthEastern Surface Seal Installed by r i H.P. ,3 e2 * Repair Work Done k Type of Pump State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth'' Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION l:) REPAIR/ADDITION I I 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: "rNumber of bedrooms Character of soil to a depth of 3 feet: _ _ _ _ Water table depth n SEPTIC TANK ❑ Type/Mfg - T- -- -Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Z Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS 0 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. 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 applica call�allquirinspec� s. Co lete drawing on reverse side. Signed X � Title: Date:` y v _ Date: a; FOR DEPARTMENT USE'dNLY _ Application Accepted by ` -date Area Pit or Grout Inspection by Date Final Inspection by Date Additional 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 95201FEE CK 4 IN O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.1/x 51 „S'(?C) r �, r [jq ¢6 / 6 7 I; EH 14-26