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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT >cs "� '" *`•"' « �' '� " I 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5�� a I (Complete in Triplicate) NVIIRONMENT�(R�L HEALTH l lE tF�ir+f�dttf.` li� � . Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor s r1 +� nation 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 62, �, J � City Lot Size PM k Owner's Name Address�L a 4 4c"L Phone 4 9-17-1 2 Contractor Addresslr Lo a4W /�License No./6 D3 �Q Phone TYPE OF WELL/PUMP: NEW WELL ❑ j WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ €`� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK— SEWER LINES DISPOSAL FLD. POOP. 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 j Dia. of Well Casing CJ-Domestic/Private ❑ Gravel Pack n �n Tracy Type of Casing Specifications �.` MPubfic Cl Other a l��Delia Depth of Grout Seal Type of Grout I I Irrigation _Approx. Dept JJ_Ea'stern Surface Seal Installed by _ Repair Work Done 2- Type of Pump :H.P. State Work4 Done Well Destruction ❑ Well Diameter Sealing Material (top 50') E Depth "° iFiller Material (Below 50') 4 J TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAM ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) � t Installation will serve: Residence{— Commercial_ Other ! Number of living units: -Number of bedrooms i} <. Character of soil to a depth of 3.1eet: # r Water table depth SEP71C TAN�K.'r� _�f �_�Type/Mfg„ Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal — Dist+ance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ) Total length/size FILTER BED ❑ D0stance to nearest: Well FF Foundation Property Line SEEPAGE PITS { I' Depth Size _ Number SUMPS ❑ Distance to nearest: Well``s Foundation Property Line b DISPOSAL PONDS ❑ !tt�. IC °`"' 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 Lork 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 errnploy persons subject to workman's compensa- tion laws of California." r' ' The applicant must call for all required inspections. Comple'te'drawing on r verse side. t Signed X 4t��ts� r _ -_ _ Title: l Date: -3 I —5P0 F. R DEPARTMENT USE ONLY I Application Accepted by Date ! ._ �— Area Pit or Grout Inspection by Date Final Inspection by to I r Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca._823-7104 EI Tracy 835-6385 r Applicant- Return all copies to: Environmental Health PermtServices 1601 E. Hazelton Ava.. P.O. Box.12009, Stk., CA 95201 I, FEE yAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH L +.EH 13-24{REV.v n 53 !l p 0._