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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT E. HAZELTON AVE., STOCKTON, CA s r� ne (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �I CoEAAW n I' le) Ag Application is hereby de to the San Joaquin Locariealt (stnct nstr ct and/or insta the rk herein ascribed.This application is Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance w'h 5a Joaquin County 0 9 Local H t Qist� (�(�� g��D �/�,e .. O ob Address' � City Lot Size PM { �A � r Ili Owner's Name MA' 1A C Address S � �0 Phone 9.23 —S15 a 1 Z n ) l� Contractor's Name��l- G, 'fes°�� License No. + �� Phone �'�`��'�� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT X DESTRUCTION ❑ PUMP INSTALLATION .51 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS C j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS f ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavat'on Dia. of Well Casing Domestic/Private ]Gravel Pack ❑ Tracy Type of Casing U �- Specifications e bas f'.0 ❑ Public ❑-Other El Delta Depth of Grout Seal :4"b Type of Grout � 1 1 [I Irrigation �d�pprox Depth ❑ Eastern Surface Seal Installed by Repair Work Don 71 Type of Pump •SJR H.P, State Work Done Well pestruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 m ti TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s 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-1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal l Distance to nearest: Well Foundation Property Line I# LEACHING LINE ❑ No. & Lerigth of lines Total length/size FILTER BED ElDistance to nearest: Well Foundation hT•Property Line R SEEPAGE PITS Cl Depth Size *Number^ ! SUMPS ❑ Distance to nearest: Well Foundation V`-Property Line . F a 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: "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."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 person's subject to workman's compensa- tion laws of California." i dThe.applicant must call for all required inspections'Complete drawing on reverse side. Signed 1 Title: Date: g r FOR DEPART M T USE ONLY. Application Accepted by - Data — Area v l •� r i a Pit or Grout Inspection by Datej` r Fina Inspection by Date�f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 359-3621 >4ftntoca 823-7104- ❑ Tracy 835-6385 Applicant,rReturn.all-copies-to:_Environmental Health,Permit/Services 1601.E. Hazelton Ave.;-P.O. Bax-2009, Stk., CA 95201 r t IFEENFO; AMOUNT DU ` AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. cam' ° 2-(Av pip r-r7-�S' g5- + EH 13-24(REV.101831 - S!4�3 EH 1426