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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT p � 3ff 3� 1601 E. HAZEL T ON AVE., STOCKTON, CA (�(� �i Telephone (209) 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. t Job Address //1�/ T� `� �! City -A Lot Size PM Owner's Name � Address `�J L d/ E'� ►�c4 tCCl7r, � Phone Contractor d `e( Address License No. PhoneT TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTSEPTIC TANK SEWER LINES DISPOSAL FLD. 'FOUNDATION AGRICULTURE WELL =O _E,R PITS/SUMPS INTENDED USE TYPE OF WELL---PROBLEM AREA (¢NS-TRU ON SPECIFICATIONS ❑ Industrial ❑ Open Botto ca, Dia. of Well Excavation Dia. of Well Casing ❑ DomesticlPriva _,�-E1 G ve ack ❑ Tracy Type f Casing Specifications 1`1 Pu ' ❑ Other F-1 Delta Depth of Got Sia Type of Grout I rngatson —..Approx. Depth I I EasternSurface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 77 ' Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 1No septic system permitted if public sewer is N 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Ll Method of Disposal /1 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 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 appliust_ 12, ati for all required inspections. Complete drawing on reverse side. Signed Xcan Title: Data: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspe do Date Final Inspection by Date IZ' 13—ir% (1� n<rr-MeRy hl,n' ervf.c k�nFri7'vf� clo elwlcvV. �✓�oitet' l-,o—e_ t�^�1'�tc +v r. C.G.{j�r/ t, 6 cldrr. S Additional Comments. Y rtr.ev�D, vv.oilc V ,,;E 10Caj!1o ;-e v.c� i—r�v /-ayslc J y ❑ Stk 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 FEE INFO. AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. -EH 3-24 IREV.t i n b1 � 5 10 � -7EH 10.28