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r APPLICATION FOR PERMIT L� ' X SAN JOAQUIN LOCAL,HEALTH DISTRICT d- 1601 E. HAZETON AVE.,,STOCKTON, CA 5,v is T"w� Telephone 42091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `1-� L✓c �} I (Complete in Triplicate) C t"� Application is heoeby 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. Job Address Z�-ic;l City Lot Size c PM .� . Owner's Name Address �- Phone Z `�_ _ 3Q/4Z+ Contractor 1 ddress �Ca[ 1�1 Gl/lr!31CN _ License No. Phone 4ad1 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 _- n 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 rD Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ©,Public ❑ Other ❑ Delta Depth of Grout Seal 1 ype of Grout ❑ Irrigation ---Approx. Depth ©=Eastern—Surface Seal-installed,by- [ Repair Work Done ❑ Type of Pump H.P. State Work Done_ tr Well Destruction ❑ Well Diameter Sealing Material (top 501 E Depth Filler Material I8elow 50') C TYPE OF SEPTIC WORK: NEW INSTALLATION C7 REPAIR/ADDITION ❑ DESTRUCTION {No ilable within 200 feet./septic system permitted if public sewer is va f+� { Installation will serve: Residence_ Commercial_ Other � ! . Number of living units: Number of bedrooms y " Character of soil to a"�pth of'3`feet'. ' Water table depth w' SEPTIC•TANK"`" J"_: pe/Mfg= � .� Capacity No. Compartments I J PKG. TREATMENT PLT. ❑ Method of Disposal - r„ ` Distance to nearest: Well - Foundation Property Line LEACHING LINE ❑ No. & Length of lines; Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line P € SEEPAGE PITS ❑Ndepthf' Size _ Number SUMPS ❑ Distince to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin clounty ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. I q/ 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-.if 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 CaliforniArE' " The applicant mu t call for all required inspections. Complete drawing on verse side. s4Signed Xzrn-, {` Title: Date: 4 3�7 FOR DEPARTMENT USE ONLY i1..•.-. Date Area Application Accepted by Pit or Grout Inspection by Date? A Fina['lnspecfiari by C/' Dat- Pit /j�7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 E -(� Applicant- Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t -i. FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIYNO. INFO �+� 7 J q + EH 13-24{REV.}/N 51 .� v 1./ 14 ry,� f7jY7� /f L�- EN 14-26