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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. Job Address 617.1 m ;a/ City�' Lot Size PM ,� ?'Sf 6 2 N lHeac� .. rJ Owner's Name J�m�S '/"rr ��. Address � !�!� GQ�1� - - Phone 3 Contractor .L Gt}SOi1 Address 572c5aC4.f,e=1004 LicenseN04� /y Phone ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION p r PUMP INSTALLATION 3--' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE, i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S b ❑ Industrial Erl6pen Bottom ❑ Manteca Dia. of Well Excavation t y Dia. of Well Casing Vbomestic/Private ❑ Gravel Pack t❑ Tracy Type of Casing �l'P,PL ___ __ Specifications. , Y �s I'1 Public F10ther CI Delta Depth of Grout Seal lOO Type of Grout S�-r_A _ I I Irrigation 9q_0-Approx. Dept"h�w,I 1 Eastern,- Surf ace'Sea1 Installed by J0^0UIf Repair Work Done 1:1 Type of Pump ,5C4b H.P. 'State Work Hone Well,Destruction ❑ Well Diameter Sealing Material (top 501 (\ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RCPAIR/ADDITION I I DESTRUCTION 1 i INo septic system permitted if public sewer is 11- A available within 200 feet-) Installation will serve: Residence— Commercial_ Other N Number of living units: Number of bedrooms N Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 n SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale 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 fallowing: "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 i ti ns. Complete drawing on reverse side. Signed X Title: 1 l C--g ._��.C�[!'/ •s-. Date: OR EPARTMENT USE ONLY Application Accepted by i AA Y&A Date ] ry Area Pit or Grout Inspection by ZY269 Date Final Final inspection by Date Additional Comments: ❑ 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 AMOUNT DUEAMOUNT REMITTEDK RECEIVED BY DATE PERMIT-NO. INFO C 7H jn/ r. EH 13-24 Jr r �� 3[ �k-L'�� of EH 144-2aM EV- sl 31 L17 i