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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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 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. Job Address c 3 -�`Y r % f �il � City a Et Lot Size all'? 44+ - PM Owner's Name L 09eZi Address /�.2�r2 fr.y Phone 3 ^3 K,2 .tContractor Address M � (/..Gl j License No. X" 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 I FOUNDATION $ L AGRICULTURE WELL ^� OTHER WELL_ PITS/SUMPS _ INTENDED USE F.TYPE OF WELL ; PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i -' c D Open -Bottom ' Y ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Privates .7 ❑ Graitbl Pack ❑ Tracy Type of Casing Specifications I i Public { L Other .,'� # Fl D1.elta Depth of Grout Seal _ Type of Grout I I Irrigation } !--Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of -Pump I H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 - Depth� Filler Material (Below 50'1 TYPE OF SEPTIC WORK: Nf_W INSTALLATION I 1 REPAIRIADDITION t DESTRUCTION I 1 !No septic system permitted if public sewer is ? t available within 200.feet.) Installation will serve: Residence Y Commercial __ Other t Number of living.units: --L_— Number of bedrooms Character of soil to a depth of 3 feet: et°tz Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ,« %� No. &Length of lines ��,t'- [ r Total length/size-40 t __ FILTER BED ❑ Distance to nearest: Well - 1 Foundation I r r, Q ��Property Line SEEPAGE PITS I Depth Size �6 tr { F Number '�► SUMPSL1 Distance to nearest: Well //01 Foundation , Property Line DISPOSAL PONDS. ❑ 1 s �r hereby cerngy mai r nave 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 Dibtrict. t rs Home owner br 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- tion laws of California." ) The applicant must call for all required inspections. Complete drawing an reverse side. Signed X �� _ -__ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �' ��. s Date/ Area i fir^ Iola or Grout tnspection by Data Final Inspection by 71,�ir/l1jG��/)Date Additional Comments: t O St% 466-6781-0 Lodi • 369.3621-- El Wanteca - 823-7104—- O'Tracy--835-6385'--•--~--- - -^ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 If— FEE +- EH 1324 (REV. i EH 14-28 i is 5 INFO AMOUNT [)UE AMOUNT REMITTED CASH RECEIVED BY RATE PERh11T NO. 70 00 70 6 U -14,1 �Z: v