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,• i . [ >J APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209),466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED y� (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. Job Address s ��T 6 AKII//e01 City Lot Size PM Owner's Name [ ozir / 469-mx-,rAddress � Phone Contractor vS Address License No. _Phone! g_'=5- TYPE OF WELL/PUMP:. _ NEW WELL ❑ 'WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �T OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -°-SEWER LINES DISPOSAL-FLD. ---- PROP. LINE s r = FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (30 ` D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications;, 4 FI Public Cl Other f-1 Delta Depth of Grout Seal _ Type of Grout' _. I I Irrigation -Approx. Depth I 1 Eastern Surface Seal Installed by ti _ Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ^Sealing Material (top 501 # r Depth x. Filler Material (Below 501 y TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is " available within 200.feet.l Installation wilt serve: Residence Commercial— Other ^' Number of living units: Number of bedrooms c- Character of soil to a depth of 3 feet: k r Water table depth G SEPTIC TANK ❑ -Type/Mfg Capacity f¢ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Y Distance to nearest: Well _ Foundation z Property.Line LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED 0 Distance to.nearest: Well ` Foundation - ' Property Line SEEPAGE PITS I 1 Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ { 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'Joaquiri'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." 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.".' ¢f The applicant ust call for all requir d inspections. Complete drawing on reverse side. Signed X Title: —. Date: Z4/ a ff FOR DEPARTMENT USE ONLY 4 � Application Accepted by Date ��j�'� f Pit or Grout Inspection b Date Final. Inspection by Date" ' C/7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑`Manteca 823-7104. .. .Tracy_a35-6385 Applicant - Return all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA-45201 FEE' INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT•NO. +.Eli 19.24(REV.1?"5) ,V c) 2C"',`C7 O _�' � `..Y It„ -EH 14-26sz,