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t , F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 'I'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 San Joaquin 4 Local Health District. [� ` p E Job Address Com ( I�'� __rr ��JJ �,,rr�� r _ City T`7C_ Lot Size�CJCJx � PM Owner's Name -o V- _ > Address Phone Contractor,- �,� Q _ Address ��]i� "_ _ _ icense No. 3 d8 Phone TYPE OF WELL/PUMP: NEW WELL ❑ ---" --- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I, FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS , INTENDED USE 3~ TYPE OFSWELL PROBLEM'AREA- `CONSTRUCTION SPE F CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca' y Dia. of Well Excavation 11 Domestic/Private ❑ Gravel Pack Dia. of Well Casing ❑ Tracy.r o Type of Casing —7— M Public ! Specifications i H ❑ Other � I ❑ pelta Depth of Grout Sea] I I Irrigation —...Approx. I Type of Grout .t Deptft.rl,{-Eastern„.,._,.;,;,,, Surface Seal Installed by I Repair Work Done D Type of Pump H p f _ State Work Done _ Well Destruction El Well Diameter Sealing Material {top 50'I Depth Filler Material (Below 50'1 i TYPE OF SEPTIC WORK: NEW INSTALLATION _ REPAIR/.ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is Installation � available within m feet.) * will serve: Residence r�LGommercial Other ' ' �Nu�mber of living units: Number of bedrooms •~ _ ' Character of soil to a depth of 3 feet:"� i"� SEPTIC TANK I Water table depth 19---�qpe/Mfg �C Capacity No. Compartments I I PKG. TREATMENT PLT. ❑ � �1�, t �i c C� C � Method of Disposal Distance to nearest, Well Foundation aV Property Line LEACHING LINE Length of lines ,. FILTER BED Total length/size ❑ Distance to nearest: r Well Fou dation'= _,� Property Line SEEPAGE PITS I I Depth Size_ _/� , SUMPS N�Inber stance to nearest: Well DISPOSAL PONDS 1-1t_,' Foundatidn _ Property Line 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 rules and regulations of the San Joaquin Local Health Dtiltrict. Home owner or licensed agent's signature certifies the fiiilowiri i cerci that in the r g g 9' �� fY� .- 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.la% s of California." Contractor's hiring or sub-contracting signature ce a 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 alifi ' The �1!K for all q "red in ction oswing on verse si e. Sign Title: Y �- t Date.• FOR DEPARTMENT USE ONLY— Application Accepted by �K z I Date // Area Pit or Grout Inspection by i Date { �� Final Inspection by bate Additional Comments: . l l,'�1 GO , �X� JA� j r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ` i7 Trac 5- 5 ! ;ZZ2. y - , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' f 1 J FEE tt" INFO AMOUNT DUE AMOUNT REMCK Y DATE LEIlo�S n PERMIT'NO. +.£H 14-24 tREV.t i H 51 J (:H 14-28