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�s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 San Joaquin Local Health District. 1) i kra.,Lot Job Address � �J J (�S'C1�/7 R M City ' `a�ySizeAcitPM Owner's Name ,rcheq (-'I 11 X Address - 'SC;1 i+'n't � � PhoneZ��2 VZ L Contractor's Name I T1 License No. _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ ,OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I7o SEWER LINES DISPOSAL FLD.1Q2; PROP. LINE 1L FOUNDATION AGRICULTURE WELL OTHER.WELL� PITS/SUMPS II INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f( W Industrial ❑ Open Bottom Manteca Dia. of Well Excavation I l Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing 5-f,. Specifications / S A D i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of rout P1 ❑ Irrigation f qt{-_Approx. Depth ❑ Eastern / Surface Seal Installed by - Ft IIF t Repair Work Done ❑ Type of Pump �a H.P. ,� State Work Done Nell Des#ruction f ❑ Well Diam t �..�...__ Sealing Material {top 50'1 w 1 V I Depth Filler Material (Below 50') r 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: Number ofbedrooms 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 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 ❑ 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 applicant must call for all requi ed inspections. Complete drawing on reverse side. Signed X � y 6,� eftoe Title: Date: �l FOR D TMENT USE ONLY f� Application Accepted by Date Area Pit or Grout Inspection by " 4ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNTT DUE AMOUNT REMITTED � # RECEIVED BY DATE PERMIT`NO. + EH 13-24(REV.10183] /O 1 LU I „� , O� 1,� �+. �b_77 EH 1428 �f G7 �? 'Ki 6