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r � APPLICATION FOR PERMIT "I6a SAN JOAQUIN LOCAL HEALTH DISTRICT 4 :` 1601 E. HAZLTON AVE., STOCKTON, CA Tele)t o'he (209) 466-6781 PERMIT EXPIRES T"YEAR FROM DATE ISSUED (Complete in Triplicate) ' Application is heieby 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 Local Health District. ;I Job Address . 1 S� City fmaPM , ` � `Qs � Phone�S2 oq I Owner's Name • L Address Irl �� Contractor !��le ress �`� f Z License No. Z I lb 3 7� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT1 DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS POS AL`FLD. PROP, LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SU 5,,_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open�'Bottom ❑ Manteca Dia. of Well Excavation -Dia. of Well Casing r Domestic/Private ❑ Gravel Pick Ll Tracy Type of Casing Specifications �, , I fl.P.ub+lic. 1 171 Other F1 Delta Depth of Grout Seal Typo of Grout' `a" _ .. Y ApproxaDryepth L I Eastern S ace Seal Installed by. Repair Work Done *T"' Type of Purr H.P. _ State Work Done Well Destruction ❑ Well Diameter s1 Sealing Material (top 50') Depth + r Filler Material (Below 50'I /-, TYPE OF SEPTIC WORK; NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is G { available within 200 feet.) UJ Installation will serve: Residence Commercial_ Other Number-of living:units:• _Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ;i 'N ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 4 f 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 SEEPAGE PITS ( I Depth. Size Number SUMPS ❑ . Distaneee'to nearest: Well Foundation Property Line DISPOSAL..PONDS ❑' : i r 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, Indrules and regulations of the San Joaquin Local Health District. Home owner or licens ant's signature certifies the follo • g: "Icertify that in the performance of the work for which this permit is issued, I shall employ any pars in such m ner as to becom ubject orkman's if laws of California." Contractor's hiring or sub-contracting signature certifies the fo wing: "I certif hat in t po f e work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of alifor 'a." The applica t mu c o all requ' d i mple rawing on re Signed X Title: Date; FO fi—ATMENT USE ONLY Application Accepted by Date "G�r/ Area Pit or Grout Inspection by I Date Final Inspection by ate `` r—�p Additional Comments: ; 9 - ❑ Stk 466-6781 ❑ Lodi-. 369-3621 ❑ Manteca .823-7104 0,T racy. 835-6385 Applicant- Return all copiei to: Environmental Health Permit/Services 1601 E.+Hazelton Ave:, P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK '`""`•RECEIVED BY DATE ?ERMIT NO. INFO CASH + EH1 -24fREV.5iNs1 EH 144-26 r 1