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Wr ._ 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 in 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 7 7�T 1• — City /� Lot Size ! C•� Z? PM Job Address G CU f� G►_ /" Phone (P 7 Owner1f 7 's'Name " • ' Q I �n Address 5 �{a RJ iv ; ?s .ti ddsn _ Contractor \ =6 License No.-3 O 7AL_Phone 3162F3;P33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:"SEPTIC TANKA 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 Cas g f El Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ElDelta Depth of Grout Seal Type of Grout roz. Depth ❑ Eastern Surface Seal Installed by ❑ Irrigation --App r 1 t Repair Work Done ElType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 i Depth Filler Material {Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION Or REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is l available within 200 feet.! Installation will serve: Residence_ Commercial v Other .. . y_ eor" ! .l Number of living units: Number of bedroom A + Character of soil to a depth of 3 fee... SEPTIC TANK [`Type/Mfg Q+ 1 [.o e/ �n Water table depth r Cm Capacitye= No. Compartments Z" _.. - - PKG: TREATfAE1VT: :PLT "❑" "' -"-F"— � a Method of Di�spoostal I Distance to nearest: Well�QS ,--Foundation d r Property Line .-s y r!r r _Total length/size r. LEACHING LINE E3 No. & Length of lines ,a FILTER BED ❑ Distance to nearest: Well Foundation" Property Line ' ' SEEPAGE PITS t� Depth Size Number "SUMPS ❑ Distance to nearest: Well Foundation_2,L— Property Line DISPOSAL PONDS ❑:, ! r n and,•that the work will be done in accordance with San Joaquin county ordinances,state 1 hereby certify that I have prepared this applicatiolaws fand� rules and regulations of the San Joaquin Local Health District. _.,_.., Home owner or'licensed agent's signature certifies$ie following: "I certify that in the performance of the work for which this permit is issued, l shall not t employ any person in such manner as to become subject to workman's oompensatiori 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 all required inspections. Complete drawing on reverse side. E T { ? Title: CA)A)&A Date: & '� Q Signed �YFOR DEPARTMENT USE ONLY f �ry r s__... �s ti Area �Aipplicat6 Accepted by Date J P� r Grout Inspection by Date Final hlnspectiori b � Date/ a � , Additional Comments: ❑ Stk_466 6781 _ ❑ Lodi 369-3621 ❑ Manteca 823-7104 _� ❑ Tracy,835-6385 Applicant- Return all copies to: Environmental Health Permit/Sfervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s CK RECEIVED BY DATE PERMIT'NO. FEEINFO AMOU".'T DUE AMOUNT REMITTED ��// .(,� +EH 1324(REV.11651 � _70 r c5c] / 7" fo EH 19-28