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APPLICATION FOR PERMIT Iq SAN JOAQUIN LOCAL HEALTH DISTRICT ,ltllnCCa�^ ��Ci ' 1601 E. HAZELTON AVE., STOCKTON, CA �tiP� cALTI h Telephone (209) 466-6781Fit�S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E�Nkv wl($tiRv1C II. (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 N0.549 for sewage or No.1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . �/ �J ,� �.,,E`�oI a2 4mr u�. �e�GrtJC%�r 6/Mfy� k•/ City `0t size PM Job Address �,, /q� /�/�- Owner's Name 6c2� ��'"^'��'" Address 1 2 OZ '�f" Phone ' h el License No..,?4C,:rZ-/ Pho R Contractor A/ G a Address TYPE OF WELI,lPUMP: NEW WELL ❑ WELL REPLACEM ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ "" ' SYSTEM REPAIR JK OTHER-O ' .DISTANCE TO NEAREST: SEPTIC TANK - r^' SEWER LINES DISPOSAL FLD. PROP. LINE ICULTURE W ' -FOUNDATION AGR OTHER WELL PITS7SUMPS., _ ..Z,:.,,.. ....K...�.Hv INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Dia. of Well Casing ❑ Industrial ❑:Open Bmtom Cl Manteca Die. of Well Excavation 1 Specifications Domestic/Private. ❑y Gravel Pack ❑ Tracy Type of Casing M Public Ll Other ❑ Delta Depth of Grout Seal } t Type of Grout I I Irrigation L_Approx. Depth I I Eastern Surface Seal Installed by 4State Work Done Repair Work Done ❑ Type of Pump .Ja H.P.�� 1 _ t i Well Destruction ❑ Well Diameter � Sealing Material (top 50'1 1 O.epth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION 1 1 eNool septic tsystem p rmeitted if public sewer is Installation will serve: Residence— Commercial_. Other Number Of living units: _ Number of,bedrooms t Character of soil to a depth of 3 feet: Water table depth '•� SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT,❑ . , Method of Disposal Distance to nearest: Well Foundation :Property Line LEACHING LINE `❑. No.8 Length of lines Total length/size x.. J, FILTER BEP T❑.' Distance to nearest. Wall FoundationPropertyLine ' SEEPAGE PITS I I' Depth Size Number r SUMPS ❑' Distance m nearest:.— Weil Foundation .Property Line w, - DISPOSAL PONDS ❑ ' r. 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 D13trict. 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, 1 shall not ' t employ any person in such inatmer as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 1 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 ofC&IflOrn ie.`.' tl I The applicant mus , fired inspe ns. Complete drawing on rreverse side. ' signs TitleDates'/9—g8 I r, DEPARTMENT USE ONLY'44 tr Date f� (/ Area t Application Accepted by l! Pit or Grout Inspection by — Date Final Inspection by Date 7 o Additional Comments:' _71 LI Tracy 835-6385❑ Stk 466-6781 ❑,Lodi 3f 31321 ❑ Man Applicant- Return all copies to: Environmental Health Permit/Sarvirxts 1601 E• Hazellon Ave., P.O. Box 2009, Stk., CA 95201 it FEE AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BV DATE PERMIT'NO. ..EH 13-24(REV.l 1"sl INFO I4-26 ) i y