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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED ICornplete 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 Roles and Regulations of the San Joaquin Local Health District. li � /f • Job Address r�� Q� � �—��'�V t G� City LOCA lkLot Size PM goo a Lr_vmc v,. !Zo i 4 L Owner's Name C1 0 t co• Address 1721 E �?FKr y1 �•, C f^�`�y a t O 10,Phone l r TN Contractor L �arr�G1�A`t r b 1-•a _Address )�1 AVvvol A YY k41)1eZ1ense No. Phone , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, 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 Dia. of Well Casing Lr Domestic/Private , ❑ Gravel Pack ❑ Tracy Type of Casing P Vc. Specifications, O � ' Type of Grout et ❑ Dena Depth of Grout Seal ❑ Itrigatio s pprox. Depth ❑ Eastern Surface Seal Installed b ' Z- .,&," y Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') w Depth Filter Material (Below 50') 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 of,bedrooms 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: VM Foundation T Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: LWI Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS p Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and chat 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 lo workman's compensation laws of California."Contractor's-hiring or sub-contracting signature certifies the following: "I certify that in the performance ofthe work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for all required ' spec- Co . e drawing on reverse side- Signed Title , Date: 3 -jiA� �f�R D PSE 1 ONLY JF Application Accepted b Date re 71 Pit or Grout Inspe n by patlenal Z inspection -g� L Fiection by pate Additional Comment _ L Stk 466-6781 C) Lodi 369-3621 ❑ Mang 823-7104 ID Tracy 83556385 W Applicant - Return all copies to: Environmental Health PemWServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNTti9Y11TTEtl CASH RECEIVED BY DATE PERMIT'NO. • EH 13-24 SftEV,1 •15.i Eli 1426 i�