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or e6l APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 74 �U p 1601 E. HAZE IT -S'`P ON AVE., STOCKTON, CA K, y� Telephone (209) 466-6781 P � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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. f Job Address _;R a CJ�� CAST � r �.! 12c� City C 1D'":e"45 Lot Size- 400 ucCrL5 PM , c�tort Fr"n iy Owner's NameAlrr ' Q Addrescs •d. 13 ax a !7,5Z'/Q Phone 62o!j) 2-7 G ContracEor tJYJ ! A T E!!eC Address ow License No.s'��Phoneol4f?-oY -alJl TYPE OF WELL/PUMP: NEW WELL', WELL REPLACEMENT El DESTRUCTION ❑ 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 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial Open ottom ❑ Manteca Dia. of Well Excavation 1 O OR q Dia. of Well Casing I Domestic/Private Gravel Pack ❑ Tracy Type of Casing TVC ar Oji Specifications l`l Public f] Other Cl Delta Depth of Grout Seal So Type of Grout I Irrigation 20_1Approx. Depth I I Eastern Surface Seal Installed by J��+ Repair Work Done ❑ Type of Pump H-P. _ State Work pone Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 —a Depth Filler Material (Below 50') � TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) t1 Installation will serve: Residence kvCommercial_ Other v Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth O SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J PKG. TREATMENT PLT. ❑ �+ DMethod of Disposal J istance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size M f FILTER BED ❑ Distance to nearest: Well Foundation Property Line c SEEPAGE PITS I 1 Depth Size �_ Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ � I 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 DrItrict. 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 persons subject to workman's compensa A lion laws of California." The applicant must call for all requi ed ins ' q pe ions. Complete drawing on reverse side. !n'� Signed X Q Q C► Title: >Q� �" Dater:nt ac �� ✓( I�/ t� �FO DEPARTMENT USE ONLY 1 Application Accepted by Date Area Pit or G`ro t Inspection by Date) Final Inspection by/ Dater=� Additional Comments: Cl Stk 466-6781 Cl Lodi 369-3621 ❑ Mantec 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box-12009, Stk., CA 9520 ' FEE CK INFO AMOUNT RUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"IVO. 71 � EH 1429IREV.1iH51 Q,UIJ lO'� l p �