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a I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 x 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. I _[ r Job Addres F E t 1"M , V ID�`= City Lot Size/no a 3 PM gy�� n �yJ �1 //� Owner's Name^�/��'p A� Address 0 C ` '' + �� 1 (`'Phone �16 8 6 ' Contractor's Name Sbv-, ir,,d� License No. Phone 13_6e� `4 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FCD. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications vl� ❑ Public ElOther ElDelta Depth of Grout.Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. '"--State Work Done— –� Well Destruction ❑ Well Diameter: Sealing Material (top 501 Depth 1 Filler Material (Below 501 (� TYPE OF SEPTIC WORK: NEW INSTALLATION F REPAIR/ADDITION ❑ DESTRUCTION ❑ (No sepfic system permitted if public sewer is I a available within 200 feet.) Installation will serve: Residence— Commercial'f Other i Number of living units: C Number of bedrooms__L__ --- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 1 --� � Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well t SO Foundation Property Line 3S r LEACHING LINE ❑ No. & Length of lines Total lengfh'/size CJS F FILTER BED ❑ Distance to nearest: Well d Foundation Property Line Q— SEEPAGE PITS ET'-Depth 2-�–x 3- Size Number SUMPS ❑ Distance to nearest: Well _ Foundation (2` l 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, 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." Contractors hiring or sub-contracting sig an lure certifies the following:"I certify th in the performance of the work for which this permit is issued,I"shall employ persons subject to workman's compensa- tion laws of lifornia." The 'pr ant at call f all eq d inspections. Complete drawing on reverse side. tt SignpAcr.-epted Title: — Date; 31 7 FOR DEPARTMENT USE ONLY j Applby �, Rlnal Date 31 rV Area b `7 Pit or Grout Inspection byDate�7�( on by Date , J Additional Comments: I r ❑ 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 il�FEE AMOUNT DUE AMOUNT REMITTED GK# RECEIVED BY DATE PERMIT N0. INFO � r + EH 13-24(REV.10183) S', oo �//' •Dam r'� r � �� + EH W26