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APPLICATION FOR PERMIT w ; SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (206) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) i 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 6 "2 - City �•��` Lot Size PM �f- %z z -XV57 9�Z- -Y-----TAd�ares Y G 2-=,= � '��1'S -Ph, x.733 Ownel°s Name -- -- ---- z Contractc�r's Name /a�} 4r66 >(-Sc1AJX` License No. y-3 Phone TYPE OF WELL/PUMP: _..>NEW WELL_.❑-._ .---.-WELL-REPLACEMENT ❑ DESTRUCTION 17 _ PUMP INSTALLATION El SYSTEM REPAIR ID OTHER El 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 ❑ Domestic/Private -E-Gravel-Pack-�- ---O-Tracy^Type-of Casing Specifications �. ❑ Public;t I ❑ Other ❑ Delta.-,, 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 50') Depth 'Filler Material (Below 501 TYPE OF SEPTIC:�WORK:--rNEW INSTALLATION-El,-REPAtR1ADDITtON= -DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) I'stallationwill serve:_Residence_ Commercial=Other /�/ �' /L �r Number of livinun its: __Number of bedrooms Character of soil to a depth of 3 feet: Water Water table depth = y t # Capacity No. Compartments SEPTIC TANK TANK El Type/M; " .* PKG. TREATMENT PLT.-[]-_„ -. - Method of Disposal Distance to nearest: Well Foundation Property Line w� LEACHING LINE Z :.1 No.'&..Length-of-lines_ Total length/size Z tFILTER BED ❑ Distance to nearest: Wei l Foundation Property Line SEEPAGE PITS Depth._ Size _ �_ Number l 5. SUMPS i ❑ Distance to-nearest:. Well V/'�� Foundation ld ` Property Lined *. 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."Contractors 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 penins subject to workman's compensa- tion laws of California." The applicant call-for-all-requiredinspec' s.-Complete-drawing-on-reve ide00 . Signed Title:-'----' Date: FOR'DEPARTMENT USE ONLY A a Application Accepted by�..-.-- - .. �� --- Date -•"'� fe ' Pit or rout Inspection by Dates " incl Inspection by O(it�fL/) Date Additional Comments: CA-4- 0 Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Applicant,'-Return-all-copies-to:.Environmental-Health Permit//Services 1601-E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201CK 0 FEE INFO AMOUNT DUE j AMOUNT REMITTED CASH `RfEC11/EIIVED BY.,„\, I_ DAP �(TE�q ERMIV NO. + EH 13.24 IREV.101931 �!( C 1 V lSlV ` A ^7W ! EH 1428