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r - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ■r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 1n 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 /�f 7�L� c}, �`n�+>�� Cityi Lot Size �r✓�— PM Owner's Name ��.rt Ar/t!Z/+t_- Address %✓t -t� Phone )` t r� Contractor Address_ License No.�£ii�^ Phone:J v�✓� < TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of GroutWin i I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. _ State Work Done Well Destruction [) Well Diameter Sealing Material (top 50') am Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 14' REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other e Number of living units: Number o bedrooms Character of soil to a depth of 3 feet: -r Water table depth SEPTIC TANK {7/Type/Mfg Capacity ° No. Compartments I PKG. TREATMENT PLT. O Method of Disposal r IDistance to nearest: Well !� ) Foundation_�'_ Property Line i1 LEACHING LINE 0—'No. & Length of lines t '3 Total length/size r FILTER BED D Distance to nearest: Well //Or Foundation 1 J I Property Line -- SEEPAGE PITS Depth s t Size . s- ` Number _? ... SUMPS Ll Distance to nearest: Well 4,11D Foundation ` I Property Line- DISPOSAL PONDS D 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 Sari 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 California." .. The applicant must call for all regr ed ' spections. Complete drawing on reverse side. Signed X A Title: _�r/U�Ll!��> J 3� . --- - Date: 6l FOR DEPARTMENT USE ONLY Application Accepted by Data Area 6.).rr Grout Inspection by 4 ate Final Inspection bye Da.rte 111 Additional Comments: _ ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT NO. + EM 13-24 IREV.1 i x S) V