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APPLICATION:FOR PERMIT SAN JOAQUIN .LOCAL HEALTH DISTRICT - 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. /. 4,. f t #a ; '•ifs %:.. } /job Address VT-7v / ,e.•_� City [-/.,v Lot Size PM, Owner's Name F Address _P't1� 2a! _ -� _* Phone �" t Contractor's Name At A1id4Z;— License No. ! e 1Ph1"on?eS TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ` .DESTRUCTION ❑ '"` "`-''•"""""` "�""`"�PUMP'INS'TALLATION— �� SYSTEM REPAIR ❑ �O�THE�R ❑ y DISTANCE TO NEAREST: SEPTIC TANK ��/O, SEWER LINES DISPOSAL FLD.�. PROP. LINES'aVf 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 _ Specifications 11 Public ❑.0ther, ❑ Delta Depth of Grout Seal 571 ` � I P ._.� Type of Grout roV , ❑ Irrigation -L-Approx. Depth ❑ Eastern Surface Seal Installed by---. .S!d&T-e - Repair Work Done ❑ Type of Pump r H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 501 Depth-'h 1 Filler Material fBelow 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (� available within 200 feet.) Installation will serve: Residence_ Commercial— Other BVI e Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg 2 Capacity No. Compartments PKG,TRE4TMENT PLT. ❑ ,: ± Method of Disposal t ,naDistance to nearest: Well F6undation}1. e(' Property Line ,LEACHING`LINE ElI No. &-Length of lines F Total length/size FILTER'BED' ❑ Distance to nearest: Well -Foundation Property Line SEEPAGE PITS ❑ I Depth-2 Size r Number # (SUMPS ❑ Distance to nearest: Well Foundation- ` y Property Line_ ^.DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will'be done in accdrdance with San Joaquin county ordinances, state laws, and "rules and regulations of the San Joaquin Local Health District. -4 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 c6mpensation.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 appli ant must call for ot allirequired inspections. Complete drawing on,reverse side. `Signed-X- i + ,,,,_. Title: n_r`. Date: t 2 d`T .I: FOR DEPART NT USE ONLY Application Accepted byA f._ Date 1-2 H Area Pit orGrout Inspection by Date Final Inspection by Date itional Comments: � tk`466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ', ❑ Tracy 835-6385 7 Ap licant- Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i 01 INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT°NO. r I I� ' 9�� i + EH 13-24 TREY.14!831 T +-'3 t.� 12- z—'� �'�.]5 3 EH 1428 f �J