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I APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT `. 1 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 ` Telephone (209) 466-6781 !PERMIT EXPIRES VYEAR FROM DATE ISSUED I! (Complete in Triplicate) ;I Application is h'eieby 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. _ Job Address � � �� City t-r� Lot Size PM . Owner's Name', r� Address 1 S Phone r:t.+4C R6, o,< 7 p 3�0 -Sa 0S Contract Address License N 0�3 ly Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Ii PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE Tq NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL-----=.- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial R ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' i ❑ Domestic/Private ❑ Gravel Pack_ ❑ Tracy Type of Casing Specifications ; M Public �I ❑ Other n Delta Depth of Grout Seal Type of Grout Ia I i Irrigation Ii _.-Approx. "Depth l I Eastern Surface Seal Installed by i _ Repair Work none ❑ Type of Pump} H.P. State Work Done Well Destruction ❑ Well Diameterr Sealing Material (top 501 r Depth # filler Material 16elow 50') P TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 EPAIR DDITION DESTRUCTION I I (No septic system permitted if public sewer is -- -- 44—. -,.-._ _ _ aii. -available-within 200 feet..) Installation will'serve: Residence_A Commercial ther <. t Number of living units:._ Number of-be obm's. 4'a ._...,,,+Character of-soil-to a depth of 3 feet:, Water.table.depth. r SEPTIC TANK • ❑ Type/Mfg! Capacity No. Compartments PKG. TREATMENT PLT. U Method of Disposal Distance to nearest: Well Foundation Property Line - F LEACHING LINE & No. & Length of lines � -- Total,;length/size FILTER BED iF ❑ {Distance to nearest: Well S5^^{{_0�Foundation A0 Property Line01) i! f / SEEPAGE PITS I -fDepth -Size' � Alumber SUMPS II ❑ Distance to nearest: Well-'/4 Foundation /d Property Linep _ DISPOSAL PONDS,-.:- C7; �� *° ��" i � i hereby certify,that I have=prepared this application and..ihat 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,thelperformance 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 k 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 applican - ust call'for al r uir d inspections. Complete drawing on reverse si II e Q Signed X - " - title: 1 / Date: !%G!'l/ C} 7 I FOR DEPART ENT USE ONLY 10 1 Application Accepted by Date � Area ii — �P or Grout Inspection by D to I Final inspection by ttt� _// (/Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ia 1 CK IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, k t EH 13-14 IRE EH 14<26 V.1/851'IF ' f _ ` !i J