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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �. 1601 E. HAZE'. TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate)' s 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 Ryles and Regulations of the San Joaquin Local Health District. sl Job Address , City Lot Size PM Owner's Name ress . \nra�.: -. Phone Contractor License No. Phones 1-%4n 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 ,RROBLEM-AREA--7 CON STRUCTIO N:SPEGIFI CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia"#of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications k ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout El — IrrigationApprox. Depth ❑ Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') 1r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will server Residence h. Commercial. Other f Number•of,living uhits: Number'of bedrooms "' r Character of"'soii to depth'of 3 feet: w Water table depth SEPTIC TANK T e/Mf ` `'� CQ p YP 9 — IZC e��.J Capacity No. Compartments ^ PKG. TREATMENT PLT. ❑ } Method of Disposal l Distance to nearest:,. . Well .Foundation Property Line LEACHING LINE �j No.& Length of lines -- X X Total length/size ' C FILTER BED Distance to nearest: Well _" Foundation-sa-C" Property Line SEEPAGE PITS ❑ Depth Size _ ' Number ✓ SUMPS ❑ Distance to nearest: Well Fo_undationProperty Line DISPOSAL PONDS ❑ w I —1-hereby certify-that I have prepared this application and that the Work will'%6 done in accordance with San Joaquin county ordinances,state laws,ander~ " 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:"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 tally or all required inspections. Complete drawing on reverse side_,___ Signed Title: __ OfU e ice/�/r Date: t FOR DEPARTMENT USE ONLY J� f"cation Accepted by Date ^r a ,� l rt o Grou Inspection by Date Final Inspection by ate� ib Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant-Return all'copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA$5201 ' a FEE INFO AMOUNT DUE AMOUNT REMITTED CASH ,RECEIVED BY DATE C++PERMIT"NO. + EH14-2fiIAEV.tie57 rr�(/ c[s'i �o dI� �� / 6W 7•�t_ ��o l