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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ft1_19 r " 1 1601 E. HAZE T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 ' PERMIT EXPIRES TYEAR 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. t7 Job Address �s �L'�AA)�'-4— a) City 77VACU Lot Size PM Owner's Name -/�lL� Address 1 �/��S � �i J Phone Contractor f (r-No. T2126 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLAC ENT)Z DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK //(� _/ SEWER LINES DISPOSAL FLD.IROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '>�-`Domestic/Private _��Gravel Pack "'(.Tracy Type of Casing AC 4_W_ Specifications FI Public 1-1Other F1 Delta Depth of Grout Seal Type of Grout L I I Irrigation / Approx. Depth I I Eastern Surface Seal Installed by _ \} Repair Work Done ❑ Type of Pump teSI&PH.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I l RFPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is 6 available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms_ Character 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 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." Contractor's hiring or sub-contracting signature certifies the following: "ice y 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 t requi dfinspections. Complete drawing on rev r side. Signed X Title: Date: ? FOR DEPARTMENT USE ONLY / rJ Application Accepted by / j _" wf,-- Date '` r Area Pit r Gr6u0nspection bye- C Date y.` Final Inspection by Date Additional Comments: '�/r`��/1 .^,� "Z��`` w'c''�� /d5 �C�G�'�' — G�G� f�'y/� O�f'c;� �,,r �'C>v< w�.�-50✓? ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 ;-J Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. r, r ♦.EH 13-24 IRE EH 14-26