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3SrU . . r APPLICATION FOR PERMIT f �- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,'STOCKTON, CA M Telephone (209) 466-6781 ` { PERMIT EXPIRES 7 YEAR FROM DATE ISSUED {Complete in Triplicate) 'F Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Ths 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 Address ='- _ Lot Size PM Owner's Name Address ._`�� 7a �.�4 GGYlta.cz r Phone 3 Contractor's Name ti/ censetiNo./6 2-373 Phone i TYPE OF WELL/PUMP: NEW WELL ❑ ---,WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ -SYSTEM REPAIR V OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_____t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i (]� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing LeDomestic/Private F7 Gravel Pack C1Sp Tracy Type of-Casing ecifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Q 11 Irrigation Approx. Dept ❑ Eastern Surface Seal Installed by ' -Repair Work_Done ❑ Type of Pump H.P. State Work Done &M 040 Well Destruction ❑ Well Diameter Sealing Material Stop 50') "1 i Depth Filler Material (Below,50') ` .`A i T .� TYPE-OF-SEPTIC—WGRK:—NEW-INST-ALL-AFION-O--REPAIR/ADDITION ❑—DESTRUCTION ❑-INo septic system permitted if public sewer.is f li available within 200 feet.) ..� Installation will serve: Residence_ Commercial_ O�t�he �': J// Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: 'Water table depth 1" SEPTIC TANK ❑ Type/Mfg ` Capacity �= Not Compartments PKG. TREATMENT PLT. ❑ Method of5Disposal rr Distance to nearest: Well Foundation Property Line g- � > LEACHING LINE. ❑ No. & Length'of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line 1. �. y s 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 Joaquin Local Health District. I 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 subcontracting signature certifies the foflowing: "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 L call r all require ' spections. 91omplete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ' Date /� Area Pit or Grout Inspection by Date Final Inspection by ff, 1, ',"'4 Date �� r Additional Comments: _ ❑ Stk 466.6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 635-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 ' f � F INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.101831 EH 14.25