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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Oistrict 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. 18.62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address �7A f t;J City Zd49 Lot Size Z,/4) 4-� PM 31 9 Owner's Name ��- sn I >✓ Address Phone ^X? Contractor Address -� License 110. .3+ 7� Phone_34 e2Z-� ,TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE/ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t fi'i Public C1 Other n Oelta Depth of Grout Seal Type of Grout _ I I Irrigation _.-Approx. Depth i 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pum4 H.P. t State Work Done Well Destruction I ❑ Well Diameter Sealing Material {top 50'l 3 Depth Filler Material (Belo",) TYPE OF SEPTIC WORK_ : NEW INSTALLATION REPAIR/ADDITION DESTRUCTION { I (No septic system permitted it public sewer is V J w,� ' .zr ,available within 200 feet.) I Installation will;serve: Residence Commercial_ Other Number of living ur ts� Number of bedto ms Character of soil to depth of 3 feet: cr �wl - -�-- � �� Water table depth 6 � SEPTIC TANK ByType/Mfg ��lt_ -U G.apacity—/�[9 _._ No. Compartments 14— PKG. TREATMENT PLT. O + tr-""" """j Method of Disposal Dista ce'to_neatest:r. 4Vell r FOLid. t4on Property Line LEACHING LINE ❑ No. R Length of linedTotal length/size ` 1 FILTER BED ❑ Distance to nearest: # Well r 4 7 dation At)� '. Property Line' h SEEP, 4GE PITS lyi'rDepth r r Size _ . .__..'. Number i SUMPS Ll Distance to nearest: We41_ }FQundatiori / Propet�y-,69e DISPOSAL PONOS ❑ - I hereby certify that I have prepared this application'and`that the work will bb-done in accordance with San Joaquin4codrlty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �� { J 1 ; Home owner or licensed agent's signature certifies the following; "I certify,th -in-thee performance of the work for which this permit is issued!I -Shall not employ any person in such manner as to become subject to wo*rnan'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 employ persons subject to workman's compensa- tionlaws of Califu`nia." ` + The,applicant must calf or II required inspections. Complete drawing on reverse side. yj' 43 1 f Signed X�/k �t Title:V1112-0,186 µ 4 ..g. Date: j FOR DEPARTMENT USE ONLY �j� �t e Application Accepted b%y 11 Date Area 12-1 tI f f Pit r Grout Inspection by Date >•6 Final Inspection by ate ! C� t I Additions! Comments: ❑ Stic 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 923-7104 EITracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 i —FEE— 0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY .� DATE PERMIYNO. ♦.EH13-241RE:V.1i95r EH 1426