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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT SCA 1601 E. HAZE T ON AVE., STOCKTON, CA_ Telephone (209) 466-6789 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 �/ �i�{ Cit � � f Y Lot Size /> PM Owner's Name IyAlr Address �� 5, Phone Yt�S" -3 67 Z- f +�a' S t: O)eXJ4 a6c E Contractor Addres��t /'� ,License No.�7 y' s if � - - Phone - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINESg:tO! DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing 1 t'� 6 15iDomestic/Private Gravel Pack ❑ Tracy Type of Casing� - -- Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _.,7 Type of Grout e- ❑ Irrigation ---Approx. Depth Eastern Surface Seal Installed by J p Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter jam,° Sealing Material (top 50') K 'gt Pn e- 1s"t ~ Depth L y Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence— Commercial_ Other available within 200 feet.I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth O SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments CJ PKG. TREATMENT PLT. ❑ S Method of Disposal � Distance to nearest: Well Foundation Property Line n� LEACHING LINE ❑ No. & Length of linesTy v� otal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well FoundationProperty Line DISPOSAL PONDS ED 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. 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 pbrsons subject to workman's compensa- A tion laws of California." Q The applicant must call for all required inspections. Complete drawing on reverse side. Signed X �� „ Title: Dew Zo-/lIC-1 �RARTMENT USE ONLY F Application Accepted by T Date �tj Lia f Area d �� Pit or Grout Inspection by Date_..- r E4inal Inspection by U Date Additional Comments: ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT N0. INFO g + EH 73-24fREV.ilH5i COs: D7c l� 7 4 g`a-3YU EH 14-26 I a J Gl �jyq� t�/6'1l� - -3 i cJ