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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 pp cation is 1 made in compliance with San Joaquin Counry Ordinance No,549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin 5 Local Health District. i, i .fob Address �J � ` City J�/` Lot Size PM � Owner's Name ole CSG_ Address Phone Contractor ," ulfl?K F0054� Address 29?0 4-245-0-VPhone No. 231/3 Phone /t�66 P?-0 TYPE OF WELL/PUMP: NINA WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINT= FOUNDATION; AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation*" Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingf Specifications I`1 Public P Other ± f-1 Delta Depth of Grout Seal Type of Grout ! Irrigation —.-Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump..I H.P, State Work Done_ Well Destruction ❑ Well Diameter'1 Sealing Material (top 50'1 Depth -I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial�ther � Number of living units: Numberr,'of bedrooms ifq r Character of soil to a depth of 3 feet: AWater table depth PKG. TREATMENT PLT. ❑ V r SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments Method of Disposal / Distance to nearest: Well Foundation Property Line LEACHING LINE 'Y?"-No. & Length of lines "7- Total length/size x` FILTER BER ❑ Distance to nearest: Well �� Foundation_ fir- Property Line 7 600 f- I , SEEPAGE PITS I I Depth I _. Size Number SUMPS ❑ Distance to nearest: 1 ,Well foundation - pro DISPOSAL PONDS ❑ -r 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 Dt%trict. 1. Nil _ Home owner or licensed agent's signature certifies the following: "'I certify that in the performance' of the work-forwhich this permit is issued, l shatl 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: "!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 for all requir d iaspe ns. Complete drawing,on reverse side. Signed X Title: rT� 2-/.7-9,0 Date: FOR DEPARTMENT USE ONLY Application Accepted by ,.L Date �-I'l^CiC7 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 Manteca a23-7104'L.,. ❑ Tracy X835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE OUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO DATE PERMIT NO. + EH 13-24(REV.riKsl �! =Oa�> I JC� ��EH t4-2a l 7S/ U