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a a r APPLICATION.FOR•PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,_STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 'I 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. Job Address City 4 G Lot Size�/� PM " Owner's Name �• Address AddPhone JJ �� # Contractor 1 �/"/ILLC� Address d. 1�y Alr,,�L.License No 7 �v2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM_ REPAIR ❑_ .., ... ,r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES / DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public" ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done, ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material /top 501 -, Depth Filler Material (Below 501. - TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION`_❑ (No septic system permitted if public sewer is available within 200 feet.) 1 Installation-will serve:;-Residence�Commercial' `''`'OtFi6e` +"` Number of living units:-I— Number of bedrooms Character of soil to a depth of 3 feet: ,4 17 Thi Water table depth E SEPTIC TANK ;0 Type/Mfg � sf ft`' Capacity o4 No. Compartments PKG.,eTREATMENT_PLT. ❑% '' -- ^T--'-� '" ''" P� `:`_ Vr �T Method of Disposal Distance to-nearest---Well Foundation ?5-o e"Ity Line i LEACHING LINE ❑ No. & Length of lines "��® /a`' "` "" T sl'lengtW/sire FILTER BED ❑ •Distance to nearest: Well' Foundation Property Line /11�hr ; 111 SEEPAGE PITS ❑ Depth Size ! Number t y { 1 � SUMPS � ❑ Distance to nearest:" "" Well Foundation -T Property Line 1 ' 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: 1 certify that in the performance of the work for which this permit is issued, I shall not k employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature f 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." w 1 The applicant must call for all r uire inspections. Complete drawing on reverse side. i Signed x__J Title: Date: # FOR DEPARTMENT USE ONLY r = Application Accepted by Date �; 5- f Area I ( l Pit or Grout Inspection by Date Final Inspection by Date 1 r Additional Comments: 4 "' i• ❑ Stk" 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823-7104 racy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. la elton Ave., P.O. Box 2009, Stk., CA 95201 f FEE . T } AMOUNT.DUE- - AMOUNT REMITTED^" CASH . RECEIVED BY'-- y�DATE' 'PiRMIT"NO Y "INFO" •� + EH13-244REV.1iAsl � '� .1 ".,` �� ..-. .._ _.,. .--4..- � --�� L�.. �..•,,.--� - EH 14-28 ..