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{ , k APPLICATION FOR PERMIT SAN JOAQUIN LOCALHEALTHDISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 'Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUI~D i (Complete in Triplicate) JI ,s r 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 Ryles and Regulations of.the San Joaquin Local Health District. :T .r:f' 11+ !'. r Job Address _631 � City lL✓![+dt� Lot Size PM Owner's Name Address ! KfKr� �l - - Phone` - t /� Contractor Addressr s &444icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMkNT ❑ DESTRUCTION LJ } 1 F k`^, I PUMP INSTALLATION ❑ SYSTEM REPAIR .W OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 i t7f Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1 Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by R l Repair Work Done 4R" Type of Pump H.P. State Work Done 1 Well Destruction ❑ . ,Well Diameter Sealing Material (top 501 Depth ` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUC ON ❑ (No septic system permitted if public sewer is ,, available within 200 feet.) Installation will serve: (Residence�W Commercial_ Other Number�of 6vm irti rus:.. .} t Number of be g•unitdroom Character of soil to a depth of 3 feet: "` Water table depth SEPTIC-,TANK_ .—_. _L1, Type/Mfg.. - -Capacity No. Compartments 3 PKG. TREATMENT PLT. ❑ Method of Disposal P Distance to nearest: Wel(: i�'+ Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length,/,Size 11 FILTER BED ❑ Distance to nearest: Well Foundation Property Line al SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line .__ DISPOSAL PONDS ❑ s' 1 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. 11 . 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.''fontractor'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 musj call for all r5Wjjd inspection§. Complete drawing on r verse side. ' Signed X � � � Title:� � I � - Date: FOR DEPARTMENT USE ONLY Application Accep d by Date Area QG i Pit or Grout Ins by Date Final Inspection by Date �j Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 Y❑ Tracy 835-6385 ' Applicant- Return all copies to: Envirorirnental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE_ _. PERMIT NO.' INFO r +EH 13-24(REV.)1135) - _ e ,9 EH 14-25 .. C) /: {b