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u APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 " (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 i Local Health District. , Job Address �3 !f TL City Lot Size ( PM Owner's Name Address A: 3 ">,9/0:aL�Ze9K�'_— Phone Contractor od 5-14 1Z:irjM6jN. Address Ri0i /t�Y /l?T>✓.a License No. Phone " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Pub{ic -- -""--D Other ❑ De1t9 "' -DeptFi of goutS-65517—::' `-""` Vpe-of Grout: "-7 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by + Repair Work Done ❑ Type of Pump H.P. State Work Done r v Well Destruction ❑ Well Diameter Sealing Material [top 501 ! Depth Filler Material 18elow 50') TYPE OF SEPTIC WORK:- NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ �No septic system permitted if public sewer is • / available within 200 feet.) Installation will serve: Residence 4- Commercial_ Other Number of living units: 1 Numhe�'of bedrooms v _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ ,jype/Mfg =�> +_ Capacity�010 No. Compartments PKG. TREATMENT PtT. ❑ �9'- ' F Method of Disposal Distance-to nearest: Well - Foundation 'Property Line �� I LEACHING LINE No. & Length of lines,_ Total length/size FILTER BED ❑ Distance to nearest: Well " l Foundation Property Line t SEEPAGE PITS ❑ Depth to Size Number� '`;s "- _ SUMPS Distance to nearest: Well ' . Foundation-c.SO 9� P+'operty Line G0 DISPOSAL PONDS ❑ � •i I hereby,certify that 1 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. 1 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 es 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 tion laws of California." I compensa- )' The applicant must call for all quired ' spections. Complete drawing on reverse side. Signed X Title Date: t�1 I FOR.DEPARTMENT USE.ONLY I Application Accepted by / Date Area A � ff Pit or Gr (� Grout Inspection by j'1L LA t` Date FinalInspectionby Date F:-1.2 —(F4 r �• I Additional Comments: ; - ❑ Stk A66-6781 -(J-Lodi_369-3621 ,7 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95 01 i • FEE # r INFO .AMOUNT,DUE- -AMOUNT•REMITTED•-- "GASH RECEIVED]BY - DATEI ftMIT-N6. +.EH1 3-24MEV.iits5 ""• 70-00'•�.. EH 14-26 UVJ } r