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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 4&6_6781RECEIVE D :1 -'W -`tet ''0 iii ' PERMIT EXPIRES i YEAR FROM DATE ISSUED �.-t.sj $ 1 $7 {Complete in Triplicate) 230t - 200 -2S Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work made in compliance with San Joaquin County Ordinance No.549 Local Health District. for sewage or No. 1862 for"well/pump and the Rules and RsERTJoaquin - Job Address —._ . Al n'&x _ /I7Zir r LCl.S7" ( rZ�' .2c/Q J� 1.50 1 (r City Lot Size PM r _. � L Owner's Name Address _ _ Phoma N ®/�1 Contractori Address License No. OZ �3�Phone TYPE OF WELL/PUMP: U I NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Z4Q'-1'_ SEWER LINES DISPOSAL FLO. ILV�k PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Privater Gravel Pack )6 Tracy Type of Casing— �� Specifications , ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal __ZM Type of ut Irrigation �pprox: Depth C1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is available within 200 feet./ Insta will serve: Residence Commercial .Other Number of livin Number of bedrooms Character of soil to a depth o Water table depth l SEPTIC TANK ❑ T e/Mf YP 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well dation Property Line l LEACHING LINE ❑ No. & Length of linesTo th/size FILTE.R BED ElDistance to nearest: Well Foundation Prope t �SEEP.AGE PITS- ❑ Depth =Size - -- Number- SUMPS ❑ Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ t 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 pbrsons subject to workman's compensa- tion laws of California." The applic st call for all require spections. C mplete drawing on verse side. } Signed Title: Date:it f 4/ FOR DEPARTMENT USE ONLY Application Accepted by Date ? Area 106 6 1. Pit or Grout Inspection j Date✓ Final Inspection by Date Additional Comments: -E] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environ[{m{ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1: F C FEE INFO AMOUNT DUE , AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. + EH 13-24{REV.1/0 51 7 i� O EH 7428 ^I Y/ q Y /� �i oC r LJT�'' •'l ^�