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s ` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. �} Job Address 1141 00 f,16 1 ,` City /00-1 t e-CG1 Lot Size JA-0-1 V_A ,- fm Owner's Name zo-4' Address tnFADiom 67 144 �4 '(hone Contractor 'WA,-,-:O[J*�//r�r ddress �Q3 Fs .6Liiren�e No.�TT Phone 6 -6 76 TYPE OF WELL/PUMP: NEW WELLif n-W EPLACEMENT El DESTRUCTION El PUMP INSTALLATION El �- SYSTEM REPAIR ❑ OTHfR k 11V`0"'Z16'V 100' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD.6 &' PROP. LINE A-4-Qlt FOUNDATION qb, 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 al Gravel Pack ❑ Tracy Type of Casing P ILC 6 c qSpecifications f'1 Public 171 Other Cl Delta Depth of Grout Seal 2.0 Type ype of Grout 1 1 Irrigation 4j)Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done T r� Well Destruction ❑ Well Diameter .z Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR)ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.I 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. LI 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 SEEPAGE PITS I I Depth Size _ Number SUMPS ll Distance to nearest: Well Foundation Property Line 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, an 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 applicant must call for jill required inspections. Complete drawing on reverse side. Signed X IV Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date l l ��- ! Area Pito Grau spection byDate f IFinal Inspection by Date It y r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 5-6385 Applicant- Return all copies to: En onmental Heatth srmit/Servic s x601 E. Hazelton }ra., Pl,,Box 3009, Stk., CA 95201 4t�� ofJ INFO ArH FEE AMOUNT DUE AMOUNT REMITTED v C RECEIVED BY DATE PERMIT NO. Q EH 13-24(pEV.5/Hsl EH 14-29