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I APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA r�� Telephone (209) 466-6781 1 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED (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. Job Address 6?157Q Ota! City ►t ' Lot Size �2 PM r r � i Owner's Name t` '� Address ?4?Z- S7 Phone 7 -7 Contractor � � _-Address f5-0 No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK 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 f'l Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout—.--. 1 k I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done 0 Type of Pump H.P. State Work Done ` Well Destruction ❑ Well Diameter Sealing Material Itop 50'i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I REPAIR/ADDITION ! I DESTRUCTION 11.INo septic system permitted if public sewer is j✓ available within 200 feet.) Installation will serve: Residence Y Commercial_ Other i u Number of living nits: lNumber of"bedrooms / Character of soil to a depth of 3 feet: � V-Si?ftd -- Water table depth \ SEPTIC TANK Type/Mfg GckCa.t � Capacity f�C3� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well .j Foundation �� Property.Line Y LEACHING LINE -❑ No. & Length of lines •y�Total length/size, FILTER BED ❑ Distance to nearest: Well r__ Foundation— Property Line �d i SEEPAGE PITS I 1 Depth /� Size Number SUMPS A' IrYDistance to nearest `-Well Foundation .Property tine DISPOSAL PONDS -CJ 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"Diltrict., 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: "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." ' The applicant must call for all required iri pections. Complete drawing on"fie/Vefse side.,: C Signed`X �� .�,. .� Title: V cn- Date: FOR PARTMENT USE ONLY 62 { Application Accepted by —" A�"� Date Area Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK# FEE MOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATED PERMIT NO. INFO /,// 18-9- +.EH13-24fRE_V.tiK5J F' 1 '- o /d �2 � � EH 14-28 V