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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address [ cJ " r�r "� City %5(KVX. Lot Size 10C1' J PM [� E Owner's Name 3.er1 � � Address i t J 1Phono UtVI D s 16 as 7 /�W t License No. 33QSphone_ Ml 18-T+ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ € PUMP INSTALLATION ❑ SYSTEM REPAIR I❑, : OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - `DISPOSAL` FLD. PROP. LINE FOUNDATION AGRICULTURE WELL .1`r 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 a ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l t`1 Public F1 Other.(„ ❑(Delta Depth of Grout Seal Type of Grout . I I Irrigation AppfoxA-Depth I I'Eastern Surface Seal Installed by + _.�? Repair Work Done,, ❑ Type of Pump H.P. State Work-Done _ Well Destruction ❑ Well Diameter A Sealing-Material (top 50') Y. i- Depth Filler Material.(Below 501 t —_ i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I'i.(No septic system permitted if public sewer is available within:200,16et.) Di Installation will serve: Residence-A Commercial— Other-17: Number of living units: Number of bpedr9 yoms Character of soil to a depth of 3 feet: �L� ol>e� ' }r' < - t � ,Water table depth SEPTIC TANK ❑ Type/Mfg _Capacity I _No. Compartments PKG. TREATMENT PLT. ❑ 0 _ *Method 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`-�j ' Property Line f SEEPAGE PITS {{I�[ Depth "size n i Number A - r V SUMPS Ll Distance to nearest: /yW"e1ll.JLV Foundation ;;IS 1 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 ordinances, state laws, an rules and regulations of the San Joaquin Local Health Diltrict. I 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 must call for all re it nspect ns. Complete drawing on reverse side. Signe Title: � L.t SLX1� Date: 4 1 FOR DEPARTMENT USE ONLY Application Accepted by Date r1 Area Pit or Grout inspection by Date Finah-lhspect n by Date�f Additional^Commonts: El Stic 466-6781 ❑ 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 95201 Y FEE CK It INFO AMOUNT DUE,E AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. +.EH 43-24 IREV.i 5) C�A EH 14-26 # F