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APPLICATION•FOR PERMIT ` . SAN JOAQ.UIN,LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES1 YEAR FROMMATE ISSUED ,.,, of ,Oz)z m i (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... ::t, ts11f"' 7 F ., fo„ as,0� 3 foo- Job Address l lf7L?i ? ar 1f•�^P city r�x �:F ~ Lot Siz PM Owner's Name L Address _T / - iC�g!�_- _ _✓ - 4, Phone - Vit �- -/License No.tor's Name ' Contrac (n] i Phone A T4 TYPE OF WELL/PUMP: NEW IVEI i- ❑ WELL REPLACEMENT-❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ,. SYSTEM REPAIR ❑ OTHER 11 4 DISTANCE TO NEAREST`SEPTIC TANK SEWER LINES r` DISPOSAL FLD. PROP. LINE w FOUNDATION. AGRICULTURE WELL OTHER WLLL PITS/SUMPS -'� °--INTENDED USE s TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial '"'` ED Open Bottom ❑ Mantua Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Piivate-,- ❑ Gravel.Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigations -L-Approx. Depth ❑ Eastern Surface Seal Installed by 'Repair Work Done ❑ Type of Pump; H.P. State Work Done d Well Destruction ❑ Well Diameter f Sealing Material Itop 501 �.1 Depth I Filler Material (Below 501 V TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION 1-1DESTRUCTI (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence—. Commercial^' Other - Number of living units: Number of bedrooms F ` .�, Character of.soil to a depth of 3 feet: 3 '.:° X 19 N Water table depth t'�G SEPTIC TAI�iC ❑ Type/Mfg i�'�'sg r�N�2'�f� Capacity 1200 No. Compartments P.KG. TREATMENT PLT. ❑ Method of Disposal J _,kvne, I �. + Distance to nearest: Well � 0G Foundation 00 0 Property Line LEACHING LINE - No. & Length of lines ' i �� i Total length/size FILTER BED 7 Distance to nearest: (Nell 20 } FoundationProperty Line :f I SEEPAGE PITS Depth?'t: Size�� Number SUMPS ,4v istance to nearest: Well��'-(�F Foundationn��J 'f Property Line �. DISPOSAL PONDS ❑ �., �. 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. "� 1.1 Y Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whictf 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." ti i f The applicant must call fa all.required,inspections. Complete drawing on reverse side. Signed ry Title: Date: FOR DEPARTMENT USE ONLY > Application Accepted by Date Area ` Pit or Grout Inspection by Date Final Inspection,6y � �hf��S�10rJ ! Date Additional Comments: 17A(I�1l) l/ _ff-I 4 17fFt: 1q,n.-T�,4C,�C-FI/(.1r !). r�i�LW&uA(� O <� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 KApplicant- Return all copies to: Environmental Health P mit/Services 1601 E. Hazelton Ave.,,P.O. Box 2009, Stk., CA 95201 �"wcr'coY�� FEE AMOUNT DUf -AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 MEV.101631 /,,..�� V u �• { EH 14-26 .��'`1 L� �1