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�* APPLICATION FOR PERMIT �I SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i! 4 .k (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 r Local Health District. r: Ul Job Address � �� City Lot Size PM Owner's Name -")e- "0ZM4AL90/ Address a Phone - ' JJ IN Contractor -Address &50 / If L9Gt-icense No. 29O F/3 Phone TYPE OF WELL/PUMF V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK /'1 dXf-, SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSp ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation If Dia. of Well Casing Domestic/Private Gravel Pack Tracy Type of Casing Jplf Specifications ❑ Public {ElOther ❑ Delta Depth of Grout Seal - J- Typq of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r 3 available within 200 feet.) CI Installation will serve: Residence Commercial_ Other a Number of living units: Number of bedrooms "( Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size k FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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. a Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which't es rrr"iit is issued;;droll not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hitingfttrSSuB-contraGtir�c`6sM--Nature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons suly" .-Wo workman's' ritensa tion laws of California." y�a The applic . ust call for all req ' d ins tions. Complete drawing on reverse s' e. i LS 07^ Signed Title: A4J + C - 3 R DEPAR ENT USE O + �"' w q6- (J til t I Application Accepted by Date o reaI � t . Pit or Grout Inspection by i Date Fi al Inspection by Date i Additional Comments: II ❑ Stk 4664781 ❑ Lodi "369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 160T E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE I� INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1324iREV.Iie51 + EH 14-2s I� I