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APPLICATION,FOR PERMIT SAN JOAQUIN:LOCAL'HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE"ISSUED 41r p � y „ (Complete.in Triplicate) 3±�7' C311r . A. 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.%9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. " + _ DI Lr_ 11r1i ,0 z a t p-�,*5- 1 1 1 , 54 Job Address 1-44 X City""Lot-Size Q PM Owner's Name 04Address Phone f Contractor's Name License No. Phone. .' TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE 0 EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ' PROP. LINE y Iw. r FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USEr TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i❑ Industrial . . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' -:p Domestic/Private ❑ Gravel Pack ❑ Tracy ' Type of Casing Specifications j ❑ Public'ter""" ❑ Other 5-D Delta Depth of Grout Seal �" Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed,by Repair Work Done ❑ Type of Pump H.P. ' State Work Done al Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 -TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DE5 RUCTION ❑ INo septic system permitted if public sewer is Cry i jw ct 196. i{-S-G 3 available within 200 feet.) Installation will serve: Residence_ Commercial— Other I Number-of living units: Number of bedrooms ( �" •1 Character of soil to a depth-of 3 feet: i' '" -" Water table depth : v ti SEPTICtTANK ` •❑ Type/Mfg Capacity No. Compartments " Method of Disposal �iCG. TREATMENT"PLT. ❑ A _ if - Distance to nearest: Well Foundation Property Line -cam LEACHING LINE -; No. & Length of lines Total length/size rt7-/FILTER BED ❑ Distance to nearest: Well:)InO- 1Foundati n -- r Prop rty Line i ;•.BEPAGE PETS Depth Size r Number e5-_ --SUMPS'f ❑ 4Distance:to nearest:-' Well _ Foundation y Property Line - o DISPOSAL PONDS -'l ❑ 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-rebulations of the'San Joaquin Local Health District.Al I Home dwner 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 mariner as to become subject to workman's oompensation 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." The applicant must call for a1�'quired inspeetio s. Complete drawing"on _ rse side. Signed�Xf __ Title: Date: e FOR DEPARTMENT USE ONLY ' Application Accepted bye i ` '� Date Area G� f Pit a5-Grout Inspection- e Final Inspection by Date Additional Comments, ❑ Sfk 466-6781.1 ❑ Lodi 3694211 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant- Return all copies to:'Environmental Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 FEE �' AMOUNT UE DJ AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT"NO. INFO r� +EH t3-2.41REV.101831 EH 14-28 "