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_d. APPLICATION,FOR PERMIT SAN JOAQUIN :LOCAL HEALTH DISTRICT }� 1601 E. HAZEL T ON AVE.;,STOCKTON, CA Telephonel 466-6781 ni fs� ' PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED „ . .{Complete in Triplicate} .1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instali the work herein described. This application is made in compliance with San Joaquin County Ordinance No.54.9 for sewage-or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address EA\C fi5l, U. City cx3��zr� Lot Size PM iy ti a• _ v Owner's Name '—0(,k "C. V` -i>-a(A,-e -Z "Address \a\, Tn J;� Phone Contractor_�>-ev '> 7�0 t PSC_- Address License No ��-_4 Phone -�4 Tri TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP'I�TION,❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR EST",,SEPTIC'iTAl � SEWER LINES DISPOSAL FLD. PROP. LINE 4 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 ❑ Public ❑ Other' ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ` Depth Filler Material (Below 51l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK p Type/Mfg Capacity No. Compart nts a: PKG. TREATMEN ;. PLT. ] � Method of Disposal ... R Distance to nearest: Well Foundation Property Line LEACHING LINE d No. &length of lines Total length/size— FILTER ength/size FILTER BED `' U Distance to neare t: Well Foundation Property Line SEEPAGE PITS III DeptFi Size Number SUMPS Distance to nearest-- Well Foundation Property Line DISPOSAL PONDS ❑1 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.th San Joaquin Local Health District. - T f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit I issued, I shall not employ any person in such�nanner alto becomelsubject 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 svbiect to workman's compensa- tion laws of Califo;nia." The applicant must call Jall requird inspections. Complete drawing on reverse side. Signed X_ 7 i Z Af, Title: Date: 4 ` �f_' FOR DEPARTMENT USE ONLY Application Accepted by Date Area F k Pit or Grout Inspection by 0 n�__ Dat. Final-Inspection by Date Additional Comments: �_ - ❑ Stk 466-6781 ❑ Lodi 369-3621 . ❑ Manteca 623-7104 c.❑ Tracy .835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601`E.'Hszelton'Av9., P.O. Box 2009, Sill CA 95201 FEE# INFO AMOUNT E AMOUNT RMED CK H _RECEIVED BY DATE P�EERMIT NO.. , + EH 13-24(REV.i/s+sl �, EH j. {