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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone Q09} 466-6781 ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -9 l (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 de cribed k This application is made in compliance with San Joaquin County Ordinance No.649.for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.— Job Address 350 'C City Lot Size(23 PM Owner's Name 's + . ""Address a Phone Contract Z Address r��. / License No. c a r j Phone V&'97S © ' t TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 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 t ❑ Domestic/Private ❑ Gravel Packi ❑ Tracy Type of Casing Specifications r ❑ Public ❑ Other ❑ Delta Depth-of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surfs efSeal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50')'-' 3J Depth I Filler Material (Below 50t,1 9 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is 6 available within 200 feet.) Installation will serve: Residence Commercial_ Other a s 0 Number of living units: Number of 4edrooms l r` Character of soil to a.depthof 3 feet:. ��-_? 1 Water table depth `Q f SEPTIC TANK M-hoType/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ 17 r Method of Disposal a Distance to nearest: WeII— _. Foundation 110 Property Line LEACHING LINE No. & Length of lines ` ° irr a Notal Iengthlsize a OK } -^n J FILTER BED ❑ Distance to,nearest: Well Foundation f0 Property Line T57 SEEPAGE PITS ❑ Depth Size ','Number - I SUMPS -.❑.. Distance to nearest: Well' Foundation ., PmperfyLine- DISPOSAL PONDS ❑ I �- hereby certify that I have prepared this application and that the work will berdone in accordance with San Joaquin county ordinances, statedaws, and rules and regulations of the San Joaquin Local Health District. :r r Home owner or licensed agent's signature certifies the following: "I certffyI wthat 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 orkman's cdmpensation 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 st call forall quired inspections. Complete drawing on reverse side. Signed X Title: V'•P. Date: �G I FOR DEP RTMENT USE ONLY { Application Accepted by _ DatBf.? Area v _- Pit or Grout Inspection by Date Final Inspection by Additional Comments: �IS24QM -42 �� 1 ✓''��`��" �� - ❑ Stk 466 fi781 ❑ Lodi . 369-3621 ❑ Manteca 823-7101 ❑.l racy. 835-6385 Vi Applicant- Return all copies to: Environmental Health-Permit/Services.1601-E._Hazelton-Ave.,-P..O._Box-2009;-Stk.;CA-95201------�� FEE AMOUNT DUE, 4 AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + M 13-24 4REV.t i e s1F Edi.14-26 ,