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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 tPERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) j 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 weli/pump and the Rules and Regulations of the San Joaquin Local Health District. I � Job.Address Hi v-1 FM �7 City asckt-oLot Size t too IPM Owner'sName 0JC-Ta(,— (7P,-PVN� Address Z4 Y L--0 Phone i � T L)E License No. Phone_ Contractor OS ibr^t° Address C1 sP�ft � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LD DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER nit DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE II t:tJf°1 FOUNDATION AGRICULTURE WELL 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 Type of Casing �`� Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout r I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by �k - Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 501 , a TYPE OF SEPTIC WORK: NEW INSTALLATION {.I REPAIR/ADDITION { I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) � h Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:` Water table depth A 3 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments } PKG. TREATMENT PLT. Ll of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I F SEEPAGE PITS i I Depth I Size Number 'SUMPS' P Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance6, 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 whiOh 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 require inspections. Complete drawing on reverse side. i f Signed Title: '7�-s-- t Date: —5— FOR —FOR DEPARTMENT USE ONLY Area C� ��15 r Application Accepted by b. Da Date Final Inspection by Date Pit or Grout Inspection by � Additional Comments: ❑ Stk 466-6781 .❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F A-0 t�.�k K STs a� � AMOUNT DUt AMOUNT REMITTED ASR INFO RECEIVED 9Y DATE PERMIT'NO. � � fl +.EH 13.24 1HEV.r/n5) ' EH 14-28