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it EI li APPLICATION FOR PERMIT( SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON AVE., STOCKTON, CA i� Telephone (209) 466-6781 co )} �i PERMIT EXPIRES TYEAR FROM DATE ISSUED u� (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Lr�� P z i {f d_y City C44_ Lot Size PM 1 11 Owner's Name � a~�7- _ S" Address Phone eY7 7 ; Contractor J544tyD Address 7N A!,_ -_d4W Y' Ae-,5 License No. yJ L76 Phone 97 I TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ j I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 ` FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications { i 171 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation ,Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done [3 Typel of Pump H.P. State Work Done Well Destruction ❑ Well;Diameter Sealing Material (top 501 Depth Filler Material (Below.501 TYPE OF SEPTIC WORK: NEW 1NSTALLATIONT' REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is I� available within 200 feet.) r i .Installation will serve: Residence__/Commercial_ Other I Number of living units: M. Number of-bedrooms -5 'Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ TType/Mfg 1!5�X L ss t-ly6- GL Capacity No: Compartments i PKG. TREATMENT PLT. ❑ 11 Method of Disposal Distance to nearest: Well liC Foundation Property Line LEACHING LINE No. & Length of lines `" - Total length/size 'y 7- ' i FILTER BED ❑ Distance to nearest: Well YO Foundation 11t1 Property Line 14 i SEEPAGE PITS I Depth Size -33 ", E Number .w. SUMPS ❑ Distance to nearest: Well Foundation s Property Line 2re ' DISPOSAL PONDS ❑ li 1 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and 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 permit is issued, 1 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 i 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 lavas of California." Ip The applicant must call for all required inspections. Comp to drawing on reverse side. Signed >L-,ti - - Title. . FOR DEPARTMENT USE ONLY .i Application Accepted by Date Area Z� it Grout Inspection b a / D �_,6W�i final Inspection by Datt�/_ `"1 Additional Comments: II ! Z- G- 7 ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 L � s! Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 6 /v G II x " INFO AMOUNT DUE AMOUNT REMITTED N RECEIVED 9Y DATE PERMIT-NO. f ♦ EH 6'24IREV,I/N51 ,,r�� ) �)j�1 ',