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.�. ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT N AVE., STOCKTON, CA 1601 E. HAZEL i O Telephone (209) 466-6781 MA PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lb (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a per7rui 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 T r ' ____ OR) Lot Size PM Owner's Name V'P\ &aloS dress �d 0 7 4P /`-Ole AL:C T J/Phone al f „ '� rContractor E/4:�J r' "'�-'-- Address Rr I License No. �� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i 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 Specifications ❑ Public ❑ Other ❑ pelta f Depth of Grout Seal Type of Grout ❑ Irrigation -----Approx.-Depth—C3-Eastern- - .Surface-Seal-lnstalled-by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction I❑ Well Diameter Sealing Material (top 501 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK:' NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.I Installation will ser✓e: Residence Commercial Other I Number of living nits:f Number of bedrooms Character of soil to-akepff",.of,31eet:.3-"' "- Water table depthSEPTIC TANK Type/Mfg opacity No. Compartments PKG. TREATMENT LTti- u .Method of Disposal L Distance-to nearest: Well Foundation Property Line e?( ' I LEACHING LINEA ❑—No.&Length of lines Total length/size 9 FILTER BED--.), ❑ Distance to nearest: Well- 1, — "'Fou—Motion Property Line-` } SEEPAGE PITS. ❑ Depth ,� Size Number SUMPS ❑ Distance to nearest: Well Foundation ' Property Line t DISPOSAL PONDS j ❑ 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. ' following: ''I certify that in the performance of the work for which this permit is issued,'I shall not Home owner or licensed agents signature certifies the employ any person in.such manner as to become subject-to workman's compensation laws of California.” Contractors 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 app cant t call for all qui d inspe tions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY ` Application Accepted b f Date ~� Area Pit or Grout Inspectio Dao , Final Inspection by. Date 1l Zl�— Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104) ❑ Tracy_ 8354M Applicant- Return all copies to: Environmental Health Permh/Services 1601 E. Hazelton Ave P:O: Box 2009, Stk., CA 95201 + r.+ -FEE-' s - A.-,..---�_.O_NT RE-�.- .'CK_ _ ...-. _ .. INFO AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT^`�.N[G0. + EH 13-24(REV.7/e 5) EH 14.29 169r((/�