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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 No. 549 for sewage or No. IB62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �- a. `J-� L/0 y" t li�-� Fb r-l� city-51 �` Lot Size - PM Joh Address /^..� , '1 LOwner's Name '1� z� 1`��, 3 h E'-Jk ("k o'ddreesss ! �� 1,,, / Phone r7 Contractor-(A J R t�1 K ft U� Address � J 0 UO Vi� IO[`� License No4 :30�a9 Phone ( TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ tV y L PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L FI Public C l Other ❑r Delta Depth of Grout Seal Type of Grout_ Lr I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done 11 Type of Pump H.P. State Work Done_ i Well Destruction ❑ Well Diameter _ _. Sealing Material (top 51 �. Depth Filler Malarial IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RI FAIR/ADDITION C--DCSTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L----C`dmmercial Other - - �' Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet: _ eii n 1j�� Water table depth L SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method or Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE L1�T4'o- 8 Length of lines Total length/size �S FILTER BED ❑ Distance to nearest: Well_ iL Foundation—2� Property Line 1 SEEPAGE PITS �pth 2 S Size �� Number SUMPS Ll Distance to nearest: Well {_L,�t__. Foundation Property Line Q� DISPOSAL PONDS ❑ 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 DiMrict. 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 subcontracting signature certih a following: I certify at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o rn. The applicant ust c all quire in Ion Com d awing on/re rr}seesi r/ Signe e: ✓� � , Date: ` FOR DEPARTMENT USE ONLY I Application Accepted by _. Date Area jL Pit or Grout Inspection G,... Final Inspection by �-" ✓I"+'-� 1 Z� Date Additional Comments: "—i! j' .�,L71 ;o"',' v ^' ❑ Slit 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6365 ,1"� �✓,�,rr%��I,ga � R I) LApplicant - Return all copies to: Environmental Health Permit/Services 16]01 E. Hazelton Ave., P.O. Box 2009, it.: CA 95201 / INFO FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. L. EH I]]�tREV EH ISM ...CCE✓✓rLLL