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Z -- �' APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 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 compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District, Job Address "L,6 M R rfi ✓ r7 ,y --- City ) �ld Lot Size 57'5-0— PM �! G5i Owner's Nam P,�s 6V�+'e�� Address vi ba..M R I Fz � Phon I Contractor Address License No. Phone TYPE OF WELL/PUMP:V 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 {n 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 h I.1 Public F1 Other C1 Delta Depth-of Grout Seal Type of Grout _ I I Irrigation —.Approx. Depth l I Eastern'N i `'Surface Seal Installed.by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 56'1 Depth I Filler Material (Below-50').. TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION ( INo septic system permitted if public sewer is vailable within 260 feet.) Installation will serve: Residence Commercial_ Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ M Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth 1 Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ r 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 the San Joaquin Local Health Diltrict. - - " 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 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 ust�call for all.require inspections. Complete drawing on reverse side. 1 Signed X Title: Date: FOR DEPARTMENT USE ONLY 22��` I Application Accepted by Date t _:):2 '�Jn I Area 7 Pit or Grout Inspection by Date Final Inspection by Data P Additional Comments: � ❑ Stk 466-6781L! Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 FEE I INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. +.EH 1324 1gEV.i/H 51 ' `-� C / EW 1428 cccJJJ