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i . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE.,- STOCKTON, CA Telephone (209) 466-6781 C t I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED •� (Complete in'Triplicate) L 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 JoaquinlCounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address rn City Lot Size PM , 'e36,. -. S�q S • r�.cl�r:- cf(o2-9cYJl Owner's Name 127- 72 e ddress Phone -J- t Contractor S 4E G s Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE k FOUNDATION AGRICULTURE;WELL BOTHER 1NELL - PITS/SUMPS _ i 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 ❑ Public ❑ Other D Delta Depth of Grout Seal Type of Grout i ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 'State Work Done �1 Well Destruction ❑ Well Diameter Sealing Material (top'50') e� Depth 1 Filler Material (Below,50') TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION_ _{No septic system permitted if public sewer is available within 200 feet.) "M Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms ; . r Character of soil to a depth of 3 feet: �` ��— P Water table depth ; SEPTIC TANK C7 T e/ f YpM9 Capacity ,' - No. Compartments PKG. TREATMENT PLT. ❑ 7) l 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 Property Line SEEPAGE PITS ❑ Depth t Size Number SUMPS ❑ 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 ordinances, 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 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 required!inspections. Complete drawing on reverse side. -�S �7 Signed - /� I Title: Date: 3 -/0 �� / FOR DEPARTMENT USE ONLY / y 1 Application Accepted by --- r to l '��` T Area 03 I Pit or Grout Inspecti _ y Date Final In on byDate �p �-+��rj..J, 1 A- ,,.�( - cz !CQli4 cv J� 'V Additional Comment ' ❑ Stk 465-6781 It Lodi 369-3621 ❑ Manteca RM104 ❑ Tracy 8354M5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, StR., CA 95201 11 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO k + EH 4-28 EH 13-241REV.I/a5) I 1