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APPLICATION FOR PERMIT — SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �� \ Telephohe 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDr„ r (Complete in Triplicate) 0 ` 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.54.4 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District., J Job Address `7 O 7 Dei ma a CityLot Size 70 PM Vrf Ci 4 d9 R f 0 d)&s) F> LP[ 1 . / to Phone 14tp3-� Owner's Name 1l�Jr 1`1 Address L 'n I V I �[? ,` /�! N "4 f CSS tP 1 Lk LlJ er t)LO i / [o. I ,Contractor T, [ i2 ddress � Icense No. Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑'. SYSTEM-REPAIR ❑ OTHER.❑ ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLC1. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑.Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f 1Public ❑ Other ❑ Delta ` Depth of Grout Seal Type of Groot ^ a ►V♦ I 1,Irrigation —.Approx. Depth ;,I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done II Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material 18eiow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other ]"'C Number of living units: Number of bedrooms v Character of soil to a depth of 3 feet: Water table depth ro SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size a FILTER BED ❑ Distance to nearest: Well Foundation Property Line M SEEPAGE PITS I I Depth Size Number P SUMPS Ll Distance to nearest: Well Foundation Property Line r , DISPOSAL PONDS ❑ k 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 rt 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 persons subject to workman's compensa- { tion laws of C lifornia." The app tic nt ust►ca for al,req d inspections. Complete drawing on reverse side. Si0 gned X `-� Title: �ti�s t � Date: FOR ENT USE ONLY x Application Accepted by 1^ Date Z b Area y Pit or Grout Inspection by Date Final Inspection by L �^ Date Additional Comments: 12 e+i L n it � 1 l��S �e S J,,_cr 1,3 ❑ Stk 466-6781 ❑ Lodi -3621 El ❑Manteca 823-7104 Tracy'8,5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNTREMITTEDC RECEIVED BY DATE..1 t/�} PERMIT*NO. +.EH 13-24 I REY.r/n 5 C' •r�� l'- ' EH 14-26 -41