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APPLICATION FOR PERMIT , s SAN JOAQUIN LOCAL HEALTH DISTRICT . j 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 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. I Job Address 6` s City '5'F49 0 r' ' Lot Size PM /—Owner's Name r f A-ni v rn U I t�� Address UO 9 :�i' /3 1;_� G -rh A_, Phone g lj-3 m ` Contractor s �� r� ! Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ° DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'i Public i i Other ,I f-1 Delta Depth of Grout Seal Type of Grout I I Irrigation __.Approx. Depth I 1 Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P- State Work Done .r Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth -1 Filler Material (Below 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DE=STRUCTION 1 fNo septic system permitted if public sewer is feet.) n Installation will serve: Residence JCommercial_ Other ailable within 200 Number of living units: Number of bedrooms Charactef of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I i LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size Number i SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F 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 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."Contractors 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." +I ff The applicant mu�foruired inspections. Co I drawing on reverse side. �y Signed X Title: Lc-J h1 '� Date, ` d � P� 4 �_ I FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by �� Date Final Inspection by �� ate _ Additional Comments: U-2 T5,�l , 7d—e2 2 ❑ Stk 466-6781 ❑ Lodi 369-3621 p (Manteca 04 823-71III Tracy 835-6385 Applicant - Return all copies to: Environ amental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI INFO AMOUNT DUE `i AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. i EH 13-24(HE riN5� 11 .� 5 �� I�'g9 -/as EH 14-28 -r 'r