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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZELTON AVE., STOCKTON, CA /I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r r ` , cimplete in Triplicate) Application is her y ma a to the San Joafiin 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. Fr+r2, r 1G ; 47�:r 1 F ', ?71 11' KLJt ` f_= r. 7 L; , [r -, � 1 -t - r Job Address A/Ft'- i 04' k r-- A, f `rf 7i 71CIL 1/= T City )(71"' /✓ Lot Size PM /IP'JrV 2T1 o2 --n3 Owner's Name 1L= ry 71' I L I7:' !. t L. 'f Address /} fC (` 11 k 1)P i f7 Phone Contractor [' t ,-Vcffess License No. �` r[ 'L/ r Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ya PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER PIL h DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE is rr. f5 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rr. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of VVell Casing LI Domestic/ Private ❑Gravel Pack ❑Tracy Type of Casing Specifications 1.7.,r r �' •r r _ I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r' I 1 Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done _ •� --- : r./,.r n Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TION I I REPAIR/ADDITION I I Installation will serve: Residence _ Commercial _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: SEPTIC TANK Cl Type/Mfg PKG. TREATMENT PLT. ❑ Distance to nearest: Well LEACHING LINE Cl No. 6 Length of lines FILTER BED ❑ Distance to nearest: SEEPAGE PITS SUMPS II Depth LI Distance to nearest: Nye Other c system permitted if public sewer within 200 feet.l Water table depth _ Capacity No. Compartments \_ Foundation Total Foundation Foundation Method of Disposal Property Line Property Line Number _ Property Line I hereby certify that 1 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 m licensed agent's signature certifies the following: "1 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 required Inspections. Complete drawing on reverse side. r Signed% �� (i....m ''^: �•='!*�:..�.•r.P Title: i ;�cl+r'r 7 f" F G L C Z'+1 �+'r Date:�sFOR DEPARTMENT USE ONLY Application Accepted by � ✓'• r Date +� r 6 Area t n Pit or Grout Inspection b/y� Date // Final Inspection by � Sir z., Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 3693621 ❑ Manteca 623-7104 ❑ Tracy -6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1110, EN 3 2 IREV. 11n5'. EN tx A INFO AMOUNT DUE AMOUNT REMITTED l:ASH RECEIVED BY DATE PERMn' NO. y.. r1o