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f APPLICATION FOR.PERMIT SAN JOAQUiN` sLOCAL2HEALTH DISTRICT �,. � . xr a :.- : 1601 E, HAZEL T ON AVE., STOCKTON, CA S Telephone (209) 466-6781 f * PERMIT EXPIRESA YEAR FROM DATE ISSUED' s ,.,. .. (Complete,in,Triplicate)-, 4%d 14 *. .a 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 H compliance with San Joaquin County Ordinance No.549.for sewage or No. 1862 for well/pump and the R41es and Regulations of the San Joaquin Local Health District. "� Job Address .S'/ 11:F-, �, , Q,. •��, '; 1. x Tt City! cc Lot Size 7'Q c PM Owners Name(Terar,1 C f),4,1 Address L5/ Cvntrac#or0 �/nu Address Q ��"'ee7_ scHerrLicense No37_- Phone9��-3�y3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑. i PUMP INSTALLATION'S . SYSTEM REPAIR ,� DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLO. PROP. LI FOUNDATION AGRICULTURE WELL a'" OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy T - ❑ clic YPe of Casing- Specifications �/ ❑ Other '❑ Delta Depth of Grout Seal Irrigation __Approx. Depth ❑ Eastern Type of Grout Repair Work Done ❑ T Surface Seal Installed by Type of Pump SG H.P. Sate Work,Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 .. Depth Filler TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ DESTRUCTION ❑ {No septic system permitted if public sewer Commercial Other is � installation will serve: Residence i available within 200 feet.i Number of-living units: Number of bedrooms l' Character of soil to a depth of 3 feet: ' SEPTIC TANK E2Water table depth Type/Mfg I PKG. TREATMENT PLT; 71- ' Capacity No. Compartments Distance to nearest: WellMethod of Disposal Foundation Property Line j LEACHING LiNE ❑ No. & Length of lines FILTER BED Tota! length/size " ❑ Distance to nearest: -yWell Foundation ' Property Line SEEPAGE PITS ❑ Depth Size SUMPS ❑ DiNumber r1 . stance to nearest: WeII' Foundation 1 DISPOSAL PONDS El Foundation Line k 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 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 1 certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall empl tion laws of California." oy persons subject to workman's compensa- The applicant ust call for all required inspections. Complete drawing on reverse side. Signed Title: p J` Date: C� _ DEPARTMENT USE ONLY Application Accepted by � Data O f fI is Area Pit or Grout Inspection by Date - inal Inspection by Date r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83�r6385 VV f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 J. FEE' AMOUNT DUE AMOUNT REMITTED INFO t ASFI RECEIVED 8Y DATE PERMIT N0. + EH 1324(REV.i/esl t EH 1426O� /S5-7 + e-7-?(p - t