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APPLICATION,FOR PERMIT J1 SAN JOAQUIN LOCAL HEALTH DISTRICT s �.� 4�h N",`` �X% 1601 E. HAZELTON AVE.,;STOCKTON, CA ' i Telephone '(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED (Complete in Triplicate) *a . ,} 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. �13Z7 �At1�nEnic��vi to;, 14L/ city ``'� � � _5 OX [5� PM Job Address ty cyto K�o Lot Size Owner's Name PA)!4'1'SQ�`_ �OILiS' Address 432-7 EA4 SCJI01n t4U6 Phone 10) ! (410 Contractor SEAR—S Address 42 00—G License No. 7ZZ 0 Phone 451- 45YI TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR I❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r �� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications N Cl Public ❑ Other ❑ Delta Depth of Grout Seal � i 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 501 " Depth Filler Material (Below 501 `— TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) 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 r SEPTIC TANK ❑ Type/Mfg Capacity No- Compartments [ / ! PKG. TREATMENT PLT. ❑ 1 Method of Disposal 111JJJ Distance to nearest: well Foundation Property Line LEACHING LINE ❑ No. & Length of lines � Total length/size FILTER BED ❑ Distance to nearest: Well Foundation • yy Property Line 7 9 SEEPAGE PITS ❑ Depth Size Number m { SUMPS ❑ .Distance to,nearest: Well Foundation Property Line DISPOSAL PONDS 0 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.. j f ( Home owner or licensed agent's signature certifies the following: 'l 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." i. k The appli nt ust c fo II quired inspections. Complete drawing o reverse side. ^� —� Signed X Title: �" � 6,Pig" Date: 4"b—?)7_ i FOR DEPARTMENT-USt ONLY (� Application Accepted by Date �'`� Area `D Pit or Grout Inspection y. Date Final Inspection by —//{ Date y Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3d2l ❑ Manteca 823-71 - ❑ Tracy 835-6385 Applicant- Return all copies to! Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AAMOUNT REMITTED CK RECEIVED BY• DATE PERMIT NO. r EK EH 113-24 4261REV.'iin51 LTJ '(rJ