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APPLICATION FOR PERMIT r ; SAN JOAQUIN LOCAL HEALTH DISTRICT r {� "�" t 1601 E. HAZEL T ON AVE., STOCKTON, CA 1Qi.tic e - Telephone (209) 466-6781 PERMIT EXPIRES 'I'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 1 Local Health District. y Job Address J _ _ ��-��LZ ) City Lot Size PM 1 Owner's Name .M&LL �.1.� Address Phone (� / Contractor W K L't n L,L - Address `�� LQ• C- -R"A) License No. -3C � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private - -C-l-Gravel Pack.... .- ._D Tracy-- --.Type_of_Casing-- ----._ _ Specifications ❑ Public ❑ Other f 1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ } Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: . NEW INSTALLATION f l REPAIR/ADDITION l I DESTRUCTION l 1 septic system permitted if public sewer is available-within 200 feet.) Installation will serve: Residence A.-___�Clmmercial— Other" - Number of living_unifs: * .f ► Number of bedrooms Character of soil to a depth-of 31eet: Water table depth SEPTIC TANK ❑"'Type/Mfg`s f"" Capacity No. Compartments PKG. TREATMENT PLT. ❑j >� � �` � Mer thod of Disposal Distance to nearest: Well Foundation iProperty Line LEACHING LINE ❑ No. & Length of lines Y Total length/sizer FILTER BED ID Distance to nearest: Welles Foundation - Propertyline SEEPAGE PITS T. i I. . Depth Size _ Number SUMPS L7 Distance to nearest: ' Well_ Foundation Property Line DISPOSAL PONDS ❑ `"' I herebycertify that I have pp �i -" y prepared this application and that the work will b done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �J-'£ _ 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 7the 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- onlaws o liforniaicant cal for II_req red_in ctions m wing on r verse side Signed Title: date: FOR DEPARTMENT USE ONLY T Application Accepted by _ _Date_ _Area, Pit or Grout Inspection by date Final Inspection by Date /Z' g * A ditional Comments: t Stk 466-6781 Lodi 369-3621 antaca 823-7104 ❑ Tracy 835-6385 ---�.. plic turn all copi s-to, Environmental.Health Permit/Services 1601,rE...Hazelton_Ave.,_P.O.Box-?M tk.,-CA.9FEE 520 r� � INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO + EH 13-24{REV.1/H s1 ' 4-29 w EH 31rC.J• .L