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APPLICATION FOR PERMIT " .. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f� I Telephone (209) 466-6781 cul~, Cyd+ .1PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �1� �• ��• ti (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 Lot Size_©f- � PM Owner's Name C7 eo / /! Gs72)ZL02 0 Address l d e -LJ ,;� Phone - 0 T ContractorT Address '""`"� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 f ❑ Industrial ❑ Open Bottom '❑ Manteca Dia. of Well Excavation Dia. of Well Casing — 4 ❑ Domestic/Private 0 Gravel Pack . © Tracy Type of Casing Specifications (1 Public Cl Other +� 71 Delta 4 Depth of Grout Seal Type of Grout _. I I Irrigation _ -Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done L3 Type of Pumps H.P.\ State Work Done Well Destruction ❑ Well Diameter! Sealing Material (top 50') Depth Filler Material*i Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ' Commercial_ Other Number of living units: -4--' Number of bedrooms 6 r 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: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED D. Distance to nearest: Well_ Foundation Property Line F SEEPAGE PIT_ S r I I Depth- '. _ Size .- - a Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ? DISPOSAL PONDS-4ci f+4 _ I hereby certify that l have prepared this application and that the work will be done in accof6ance with San Joaquin county ordinances, state laws, and :-'..-rules and regulations-6f-the San Joaquin Local Health District.! ,,� Home owner or licensed agent's signature certifies the following2{,�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 to workman's compensation laws of California""Cdritractor's•hiring or sub-contracting signature certifies the following:'K I certify that in the performance of the work for which this permit issued, I shall employ persons subject to-workan's compensa- :r, ;._ - tion laws of California."` The applicantcall for all requir "inspections. Complete drawing on reverse side. Y Signed X - ----- Title: '01,� Date: i lE l FQ DEPARTMENT USE ONLY �e Application Accepted by — `E�,t,..n�/\ I Date -�`�^ Area `iUl A J Pit or Grout Inspection by OE �DateFinal Inspection by "Dat 1 Ly Additional Comments:: C� r ��/ / D"Stk 466-6781 ❑.Lodi 369-3621 'D Manteca 823-7104 ,,,. -0-"Tracy .835-6385*"' � v�k Applicant - Return all copies to: Environmental Health Permit/Services 1601..E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE INFO CT DUE AMOUNT REMITTED- OK H - RECEIVER BY DATE PERMIT NO. EH13-24(REV.1/K51 -��,V �] EH 14-M `0�. �-+ v 4.0 . t