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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT it 1601 E. HAZE T ON AVE.,'STOCKTON, CA Telephone (209) 456-6781 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 l Local Health District. !i _J Job Address 33 LL city Lot Size x PM Owner's Nam �' 4"f j Icer Address ��r l2 �� `T9A4-- Phone � S Offer's NameiGAG {�E �t{ense No. Phone s7Sy TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W 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 El-Gravel Pack ❑ Tracy --Type of Casing — 'Specifications- —"' ❑ Public 1-�, ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r 171 Irrigation i _4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work-Done ❑ Type`of Pump H.P. State Work Done Well Destruction ❑ Well Diameter . . Sealing Material Itop 50'F .1� SA!E_A MIX rr• Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 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: I� Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT..❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line ii LEACHING LINE, ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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'Uoaquin 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."Contractors 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 applicant st call for all required inspections. Complete drawing on reverse side. Signed X (Y lo-t�O�fNYl�x� Tido:� Date: 2+-5 4- 4 II FOR DEP TMENT USE ONLY Application Accepted by Date '2s—�- Area II 11Pit or Grout Inspection by 'I Date Final Inspection by Dates II Additional Comments: ❑ Stk 466-6781 ❑ Lodi I0 369-3621 ❑ Manteca 823-7104 Tracy $35-6385 Applicant- Return all copies to:6Environmental Health Permit/Services 1ODr E. Rhrelton Ave., P.O. Box 2009, Stk., CA 95201 Ij FEE INFO AMOUNT DUE AMOUNT REMITTED k�Q+1 C'tR Hf RECEIVED BY DATE PJE�RMIT-'7NO. I + EH 13-24(REV.101831 vp EH 1428 if i