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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. � I Job Address rJ City Lot Siie PM Owner's Name f�S'�' Address � _/- CJ bone _e 3 ��6� e�DD,,4n��l,�l�F.�� /� y�7 �' 7- .C_ .. Contractor�13L•��'C b r ddress '-� rC � � License No. Phonef TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO EA .CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bot ❑ Manteca ' .j Dia. of Well Excavation Dia. of Well Casing EJ Domestic/Private 11ack -❑ Tracy Type of Casing Specifications _ l 1-1 Public I_1 Other ,Cl Delta Depth of Grout Seal Type of Grout - 11 lrrigatio �.-Approx. li-Dept ' { I Eastern Surface Seal Installed by - , it Work Done ❑ . Type of Pump l " H.P. State Work.Done Well Destruction ❑ Well Diameter Sealing Material (top 501 DepthFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION l 1 (No septic system permitted it public sewer is available within 200.feet_► Installation will serve: Residence Commercial Other Number of living units: Number"of bedrooms Character of soil to a depth of 3 feet:' �""'�-•ice -Water tattle depth SEPTIC TANK ❑ TypelMfg �� Capacity t No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r r Distance to nearest: Well � � -Foundatian-ham"'"'"'" Pr`60&ty.Line - t 0 d 'G� Total len th/size LEACHING LINE ❑ No. & Length of lines _ g T t FILTER BED r ❑ Distance to nearest: Well &R) Foundation Property Line k SEEPAGE PITS i I Depth Size L-d Cy Number -- SUMPS i ❑ Distance to nearest Well _ Foundation -Property Line 0..7 -4= .� 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, and Q rules and regulations of the San Joaquin Local Health Di1trict. 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, l shall not 0 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 parsons subject to workman's compensa- tion laws of California." A] The applicant must call for all required in pections. Complete drawing on reverse side. Signed X J Title: J Date: - I}} FOR DEPARTMENT USE ONLY ] � I Date Z 'F �4. Area Application Accepted by , Pit or Grout Inspection by Date Final'Inspection b Data- F i Additional Comments: (� c" 14" S v r 11,4c ""J r``" 4,1 LY'Y t r W-&V- ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box,2009, Stk., CA.95201 f FEE AMOUNT DOE AMOUNT REMITTED CASH RECEIVED Ely DATE PERMIT NO. INFO _ +� Q +.EH 13-24 rFiEV.t i x 51 - 'V`-"' �. .. �f 1'C.� ` � - EH 14-2tS �� 7�