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x : ¢ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDX c• .(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 don is made in compliance with San Joaquin County Ordinance No.569 for sewage or No. 1862 for well/pump,and the Rules arid!Regquin Local Health District. ' AuoX I Itk-) H611 I S L4 Jab Address `. .City Lot Size Owner's Name V I C-t-�tdxr 1r' V,, —L'sL114M�D AdMdrX m S � Phone /}n_ \� I Contractor L_11I_I rlCl.��5A8dress �^ icense No.g3_0 Phone 9,0 ~ �'"1.•uiPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 �`"'• :.o'. PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ I f� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I_ INTENDED USE TYPE OF WELL PRO13LEMAREA CPECIFICATIO�JS ❑ Industrial El Open Bottom ONSTRUC710N 3❑ Manteca Dia. of Well Excavation r Dia. of Well Casing ❑ DomestWPrivate ❑ Gravel Pack ❑ Tracy (•Typejof Casing • Specifications ❑ Public ❑ Other ❑ Delta Depth oT Grout Seal I Type of Grout t O•Irrigation r •pprox. Depth,; ❑,Easiem.�.r.�{ Surface Seal Installed by ( e Repair Work Done.10` Type of Pump - ' �..E- H.P..""'"�• (. -' State Work Done_ Well Destructidn F❑` -Well Diameter Sealing Material (top 50') 1 t p ' T �'I j I� Depth Filler'Material (Below 501 I �) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 1 ❑ INo septic system permitted if puBlic sewer is t' available within 200 feet.) t ej • Installation will serve: Resi nce— Commercial Others + t Numlier of living units: Number ofbadrooms z Character of soil to a depth.of 3 feet: —Water Water table depth i SEPTIC TANK Cl Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE - ❑ Ne'8 Length of lines I _ Total length/size �'s FILTER RED LN'/Distance to nearest: Well Foundation Property Lire I SEEPAGE PITS ❑ Depth Size Number k SUMPS .. ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ta, ' 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 1:..1 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 permh is issued, I shall not ploy any person in such manner as to become subject to'workman's compensation laws of California."Contractor's hiring or sub-contracting signature c 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 to California. - •� The applican at call for II re ired Crple drawing on reverse side. Sl Title: Date: Z ��FOPytEPARTMENT USE ONLY0�4 i ` 1�1 Application Accepted by ADate Area 7 O Pit or Grout Inspection by r Date Final Inspection by Date . Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 3693621 d Manteca 823-7104 ❑ Tracy 836-83� Applicant- Return all copies to: Environmental Health Pern it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED - RECEIVED BY DATE PERMR NO. INFO /�--r �j.•t ♦ EH W26(REV.Vaal / 0 • 0'0 �h5 o l i-•I/1 O 1-1544 EH 13-24 t �/\ TS 1