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� ry I L APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA _ Telep06ne (209) 466-6781 f f PERMIT EXPIRES 'I'YEAR' FROM DATE ISSUED" A 'j iCorrlplete m'Tfiplica#e) . Y ......,� ;art:.$ , ,.t-c - '.: 'L '...; . . . % t:t•' Application is hereby made to the Sari 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address_� ,� �[� ,iy�149,��l �" yCity iz PM I Owner's Namev E'y r � yl 74ddress X, ` 3 Phone = Contractor Address " License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION + it t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE . ,FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USETYPEOF 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 i ❑ Other ;❑ Delta Depth of Grout Seal Type of Grout + i, ❑ Irrigation {d _--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done.-❑ Type of Pump H . a State Work Done Well'Uestru tion 0 Well Diameter titSealing Material (top 50') S Ark MIA-_ r Depth FillerrMatenal [Below 50'1 W ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic s stem-permitted if public sewer is t available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms -n- Character of soil to a depth of 3 feet: - ' Water table depth'- h, SEPTIC TANK ❑ Type/Mfg -r �' Capacity ° No. Compartments PKG. TREATMENT PLT. ❑ � ; Method of Disposal Distance to nearest:' Well Foundation Property Line } f LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest:- 'Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number . SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ T I hereby certify that I have prepared this application and-that-the work will be done in accordance with San Joaquin countyordinances, 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 I=>` employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature 4 certifies the following:" rffy 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 Californi .' The applicant must for all r quire in pections. Complete drawing on reverse side. Signed Title: �Q Y Date: ` FOR DEPART ENT USE ONLY r i, Application Accepted by Date -2Z a Pit or Grout inspection by AJ' Date Final Inspection by Ja'Date Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 5 a FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED.BY DATE PERMIT"NO." E 1 I + EH 13-24(REV.E/85) - - t EH 14-28 d J_ .