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Y APPLICATION FOR PERMIT ^Q 7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 � PERMIT EXPIRES TYEAR FROM DATE ISSUE l illy � O (Complete in Triplicate) 90 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the v� #UiE d d. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. IB62 for well/pump and the R Va g s of the San Joaquin Local Health District. . i �' -- ENVIRONMENTAL HEALTH 41 Job Addres r City �= LoQEr �rr� � PM r Owner's Name, -- ^ Address�J-.3O 0 '1- Phone Y'Yd rI Contractor Address License No f(.�L3 23 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AG lldoLTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A'FtEA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ; Specifications Fl Public t ❑ Other n Delta Depth of Grout Seal Type of Grout_ _ f-t'lrrigation _._Approx.-Depth I I Eastern Surface Seal Installed by _ -- - Repair Work Done @ I Type of Pumrp 14d.�i� H.P. State Work Done Well Destruction ❑ �Well Diameter Sealing Material (top 501 r b Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) V f Installation will serve: Residence! Commercial_ Other r1 Number of living units: Number of bedrooms t h Character of soil to a depth of 3 feet: j Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments (� t Method of Disposal L PKG. TR�ATA i/ENT'PLT' ❑ l osal P `" `' """s'Distaa e�to nearest: Well Foundation - Property-Line - 1 't LEACHING LINE 5 ❑ No. & Length of lines I Total length/size f .r FILTER BED ❑ Distance to nearest: Well kfoynclation I Property Line 1 l SEEPAGE PITS I I" Depth t Size f �� Number I SUMPS ❑ Distance to nearest: Well r Foundation 1 Property Line t DISPOSAL PONDS ❑ l_;s y 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-6)-San-Joaquin-local-Health-District, ----- --�-r— ----- --- ^ Home owner or licensed,agdnt's signature certifies the following: "I certify that in the perfIrMance of the work for which this permit is issued, I shall not employ any person in su6A manner as to become subject to workman's compensation lawsiof,California." Contractor's hiring or sub-contracting signature II 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."� 1 l � k The applicant must call for all required inspections. Complete drawing on reverse side. [ r tier [ Signed X �✓TFi � ,- _ - Date: 41;/rie( R DEPARTMENT USE ONLY{ Application Accepted by Areal Pit or Grout Inspection by ate Final Inspection by � Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 19 Tracy 835-6385 k ` Applicant- Return all copies to: Envii 6nmental Health Permit/Services 1601 E.,Hezelton Ave., P.O. Box 2009, Stk.; CA 95201 E i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH +.EH 13-24 IREV.i)m sls_Ov 90^ 1333 EH 14-26 t