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I APPLICATION FOR PERMIT SAN JOAQUIN`LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466=6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Trjpllcate) "'< ! T!f 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.t4 t;,A > Job Address _. r/ p 6_91w if i City, Lot-Size x {`'` PM 5 Owner's Name Address Phone azc r Contractor Address e — License Na.4' �_(L_Phon TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,TO NEAREST: SEPTIC TANK, SEWER LINES,' -- DISPOSAL FLD. PROP. LINE ?.. r.. FOUNDATION! AGRICULTURE WELL�OTHER_WELL "' PITS/SUMPS _ INTENDEDUSETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrid' i ❑ Open Bottom ❑_Mantec!,,.,.* Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel`Pack ❑ Tracy Type of Casing's Specifications ED Public ❑ Other ❑ Delta Depth of Grout'5eal Type of Grout ❑ Irrigation ! ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P: State Work Done El y : ...,d Well Destruction Well Diameter � 'is � Sealing Material:{top 50'1 . ' 4 . oar r Depth j►�- �_-. �Filler�ateriai;{Below 50') V TYPE OF SEPTIC WORK: NEW INSTALLATION-F] REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence— Commercial_ Other - I' Number of living units: Number•of bedrooms Ur Character of soil to a depth of 3 feet 6Water table depth , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method•of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to riearest: Well Foundation Property Line ail SEEPAGE PITS; ❑ Depth Size Number SUMPS ❑ Distance 7to nearest: Well FoundationProperty Line f DISPOSAL PONDS Lli q 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. Home owner or;Iicensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not f` 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." r The applicant f6ult call for 9 req uir ins ns omplete drawing on reverse side. Signed Title: R _ - Date: 4 FOR DEPARTMENT USE ONLY Application Accepted b Date f 2` Area Pit or Grout Inspection y Date Final Inspection by7 d Date Additional Comments: 17 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 E1,Tracy 835-6385. ` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 A i FEE k INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT"N0. `^� 1� + EH 13-24(REV,1/851 —\ ,. IV EH 14-26 1 f