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a APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT J, 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `� ••, (Complete in Triplicate) I 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. 1851 for well and the Rules and Regulations of the San Joaquin Local Health District. r� s Lot Size G Xl�b PM L City Job Address t - 'a_ '.v. - - Address:,_ ------ Owner's Name - xy ';' ... `;�+j �--�`' ' �y t — Phone - .-.-� - _261> `. .,r License No. Contractor r` Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 15 DESTRUCTION LJ r � PUMP INSTALLATION 11SYSTEM REPAiR1 ElOTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing !` ❑ industrial ; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications Type of Casing ❑ Domestic/Private F ❑_Gravel Pack 0 Tracy Depth of Grout Seal Type of Grout . {] Public ❑ Other [I Delta II El irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by State Work Done ( Repair Work Done ❑ Type of Pump t Sealing Material (top 50'1 ' c F Well Destruction ❑ Well Diameter g r t Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW IN ❑ REPAIR/AD[}I�ION DESTRUCTIOV❑ ((NNaiiablticwithin em rmiitted if public s(;;;er,is Residence_ Commercial Other _ f �`^p�il�Z I Installation will serve: Res � �J Numbe1 t (((JJJ f-living units: Number of bedrooms Water table depth 1 Character of'soil to a depth of 3 feet: t I t- � Capacity No. Compartments SEPTIC ''NK [D TypelMfg Method of Disposal PKG. TIREATMEN•T_PLT. ❑ t —Distance � Foundation Property Line � to nearest: Well € � i € Total length/size LEACHING LINE ❑ No. & Length of fines i Property Line t ❑ Distance to. nearest: Well Foundation FILTER BED [ t Size Number SEEPAGE PITS ❑ Depth Y Property Line SUMPS ❑ Distance to nearest: ` Well Foundation i DISPOSAL PONDS ❑ _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.— c 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 hiring or sub contracting signature 's compensation laws of California."Contractor's certifies the following: certify that s the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- r tion laws of California." I The applicant dist call for Il required inspections. Complete drawing on reverse side. 7 7Title: Date: Signed DEPARTMENT USE ONLY Date Area A�_ Application Accepted by F I PRd.'it q flare P Date Final Inspection by Pit or Grout Inspection by Additional Comments: /J C�4� 0 Stk 466-6781 •❑ Lodi 369-3621 ❑ Manteca 623 7104 ❑ Tracy 83x6385 Applicant Return•all copies to;.Environmental Health Perrrrlit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT''NO. INFO AMOUNT DUE AMOUNT REMITTED CASH + EH 13-241REV.t/851 EH 1425