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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT # 1601 E. HAZELTON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. , �r�— "IC 4 1 City Lot Size PM Job Address f pp f�fac ;3 ��. �/f= r7 J<t I Phone {as��dc � Owner's Name ""' J�I�� Address ss�� p � ContractoA) •d� �/I Rt �1�r Addr 1" O F� L �-2icense No. Phone 74 '1 0 TYPE OF WELL/PUMP: NEW WE WELL REPLACEMENT E71DESTRUCTION O PUMP 1NSTALLATI SYSTEM REPAIR ❑ OTHER ❑ � l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD.��n ' ''-.-_ PROP. LINE , .._ FOUNDATION A2Q { AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (n f.1 T e of Casing Specifications �\ Domestic/Private ❑ Gravel Pack= 11 Tracy YP f`l Public r i Other ❑ Delta Depth of Grout Se - f Type of Groul +1.4 .— o ti C' IM 4 T--cSt�A4 I I Irrigation ..Approx. Depth 1.1 Eastern Surface Seal Installed by, Repair Work Done ❑ Type of Pump. :'u h - H.P. � State Work Done Well Destruction ❑ Well Diameter # Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATI` 1 REPAIRJADDITION l I DESTRUCTION-[ 1 INo septic system permitted if public sewer is pailable within 200 feet.) Installation will serve: Residence_. Commerc Other ( .. I. Number of living units: Number of bedrooms Character of soil to a depth of 3'feet:c4 Water table depth e SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I at the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that i have prepared this application and th rules and regulations of the San Joaquiri Local Health Diltrict. I 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 applic�t.t�&.11 �req �insions. Complete drawing on reverse side. f Signed Title: � ��F'-.�tr A' _ Date: �; /_— R D �RTMENT USE ONLY f Application ccepted by Date Area f� iJ ate �v Pit ar rou Inspection by Date nal Inspection by 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, Silk., CA 95201 r AMOUNT DUE1 AMOUNT REMITTED CK RECEIVED BY DATE PERM1T'NO. FEE CASH 1 INFO 12 p yy�� jr i 1 +,EH13-24(REV.EH 14-26 tiiH5i