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w C3 APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA V �C Telephone (209) 466-6781 n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) NTAL HEALTH ENVIRO?YE./ / r S n Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or In"the work haxein isi6e�1, made in compliance with San Joiquin County Ordinance No.50.9 for sewage or No. 18M for well/pump and the Rules and Regulatiwts of the San Joaquin Local Health District. „ ^ Job Address998 Ftp 1 �Q � �� * t`^'�"` C p City.'//�,( >�fLot,Srse }�PM Owner's Namye�" ✓ ' 'It�u'*M�'/1' T'`� Address / d 2 ,14q / Phone 7v /�'0'3�,/ Contractor >_`. -��+ �"`"""'- Address�T6 A � /.1'c.�`^� License Nomo�7� Phom'4Z44-A';I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION E3 SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IR Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal r _: Type of Grout ❑ Irrigation .----Approxr-Oepth--0 m� =East ,Surfs -Seal Installed by�'-s"--'- ' C Repair Work Done A& Type of Pump H.P. � State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONO REPAIA/ADDITION ❑ DESTRUCTION ❑ (No septic system penrtitted H public sewer is available within 200 feet.) -installation will serve: Residence j Comritercial— Other -Number of living units:— Number of bedrooms Character of soil to a depth of 3 feet: T Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE `❑ No. & Length of Ilnes Total length/size FILTER BED d' -Distance to nearest: Well Foundation Property Line l SEEPAGE PITS ❑ Depth ��- Size Number I SUMPS ❑ Distance to nearest: ^'Well_• Foundation Property Line DISPOSAL PONDS ❑ -- I hereby certify that I have prepared this application and that the work will-ba done in accordance with San Joaquin county ordinances,state laws, 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, I shall not employ any person in such mariner as to become subiect to workman's compensation laves ofzlde f a."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is isauad.I shalt.employ persons subject to workman's compertse- tion laws of California." The applicant must call for all qu'�d In_s�pectio/ns�C orn to drawing reverse side. I�j p' Signed x r � i�LTitle: Date:` -I -d 0 FOR DEPARTMENT USE ONLY Application Accepted by -�' �^ -'- 1 Date Area - u Pit or Grout Inspection by Date Final Inspection by Dtt[e Additional Comments: ❑ Silk 466-Ml ❑ Lodi 3893821 ❑ Manteca 8Z3-7104 .❑ Tracy 83"M Applicant-Return all copies to: Environmental*Health Permit/Servkas4801-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 tr 0 AMOUNT DUE N/T/RFIAnIT'TED CASHFEE RECEIVED BY DATyE�^�//�� PERMR NO. IN