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APPLICATION FOR PERMIT SAN JO_AQUIN LOCAL HEALTH DISTRICT 1601 E�HAZEL T ON AV15-, STOCKTON, CA Telephone (2091 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 herei Regulations 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. 4, Job Address ' 112 IL� City �t� Lot Size / PM i i r. ,./�i Tr.. Phone Owner's Name WAddre ;� �a li Contraoor_'s.Name /�L�J�B • W� License No. 44!�C)-17z- _'!Phone < TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP�INS,TALLATION ❑r-4j` SYSTEM REPAIR Cr 1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINIFS' DISPOSAL FL PROP. LINE FOUNDATION AGRICULTURE WELL BOTHER WELLI ITS/SUMPS INTENDED USE —TYPE OF WELL ""PROBLEM'AREA—C'ONSTRUCTIOW SPECIFICATIONS El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia: of Well Casing Domestic/Private El Gravel Pack LJ Tracy Type of Casing '' ' f= Specifications E3 El Public I El Other ❑ Delta Depth of Grout Seal ` s ' –� Type of Grout ❑ Irrigation ---Approx. Depth 11Eastern Surface Sealfinstalled by -- - Repair Work Done El 'Type of Pump H.P. ti State Work Doner f 5ealin Material (top 50'1 1. f 0,1 Well Destruction ❑ Well Diameter 1 g j F Depth Filler Material (Below 56') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No'septic system permitted if public sewer is available within-200 feet.) Installation will serve: Residence Jle Commercial_ Other ' Number of living units: Number of bedrooms Character of soil to a dept f 3 feet: I Water table depth —SEPTICTANK �7 Type/Mfg `� :_�""��— Capacity art- i No. Compartments i Method of D sposal PKG. TREATMENT PLT:❑-�- r i -j ¢ f " `Distance to nearest: Well,�R Foundation.��_._ Prope t Line' All LEACHING LINE ! �No. & Length of lines, �r,�,� F Total length/size FILTER BED ❑ Distance to nearest: Well sariJL7� Foundation ia,�C Property Line ZA& f N 7 i SEEPAGE PITS Oepth .�-.0 Size �� Number . � .. f i SUMPS ❑ `Distance-to nearest: Well Foundation . Property Line DISPOSAL PONDS ❑ • iCL *w► w gc 't - i" ' ' I hereby certify that I have prepared this application and that the wdrk'will be done:in,gccordancewith S Joaquin county ordinances, state laws, and rules and regulations'of the San Joaquin Local Health District` .: ti r °e Home owner or licensed agent's signature certifies the following: "I certify hat 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 all Tequired inspections. C plate drawing on roverse,side. - 1 l 1. Date: /�� Title: Signed ;FOR DEPARTMENT-11SE ONLY , d � ?�).4 n fer,�' Area` ¢ Application Accepted by _.. n ..�1] �h" L e,Date tt or Grout Inspection by iuc— Date 1"�1l^R>�Fina1 Inspection by Additional Comments: ❑ S'tk-466-6761: �❑Lodi 369.3521 ED Manteca 8237104 ❑.Tracy 835-6M Applicant–Return ail copies to: Environmental•Health-Permit/Ser6ices 1601�E-,.Ha?elton Ave., P.O. Box 2009, Stk., CCA�95201 e t FEE AMOUNT DUE AMOUNT REMITTED `"'CAS RECEIVED BY DAME�g PERMIT'NO. INFO N,4 r,, if o4 +04I 3-24[REV.101831 EH 1428 _ J `�. " � IFF