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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT FILE G 1601 E. HAZELTON AVE., STOCKTON, CA • Telephone {209} 466-6781 pall � � PERMIT EXPIRES 1,YEAR FROM DATE ISSUED (Complete in Triplicate) .. 0��, � �� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein escri Th plication is made in compliance with San Joaquin County Ordinance Na.5A9 for sewage or No. 1B62 for well/pump and the Rules and AeggMations of the San Joaquin Local Health District. ENV�IRON'9M"r tiITAL 14EALTH PERMIT l SEQVICES Job Address .J _4i/Qs3r� �[ll�.r+/GR. �r City Lot Size PM Owner's Name A4,;eX4." re Address 7 7 7, Phone Contractor Address IIJA license No.T�G.4'76 Phone - TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C' SYSTEM REPAIR 46;- - OTHER ❑ DISTANCE TO NEAREST: SEPTIC:TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS t i, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P4-Bomestic/Private Q Gravel Pack 11Tracy Type of Casing Specifications f71 Public 17 Other R Delta Depth of Grout Seal Type of Grout f I Irrigation —Approx. Depth I I Eastern dace Senl installed by _ - Repair Work Done (J Type of Pump l H,P.� Z _llState Work Done_ Well Destruction ❑ Well Diameter Sealing Material(tap 58'I Depth Filler Material (Below 501 1 ! TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is " available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of sail to a depth of 3 fe$t; '- Water table depth a SEPTIC TANK -❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.IJ ' Method of Disposal Distance to nearest: - We11 Foundation f Property.Line r LEACHING LINE 0 No. & Length of lines Total length/size 'FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Size Number SUMPS L-1 Distance to nearest: , Well Foundation Property Line 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 DWrict. j Home owner or licensed agent's signature certifies the tollowing: "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 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 mu cal all required inspe ions. Complete drawing on reverse side. Sign Title:d ��a 2 Date: 7 8 y FOR DEPARTMENT USE ONLY r:• Application Accepted by Date �Q r &I jo Area Pit-or Grout Inspection by Data Final Inspection by Det. - j Additional Comments: ❑ Stk 468-6781 0 Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant• Return all Copies to: Environmental Health Permit/Services 1601 1=, Hazelton Ave., P.Q. Box 2009, Silk., CA 95201 , i FEE _ I INFO AMOUNT DUE AMOUNT REMITTED CCAKSH RECEIVED 8Y DATE PERMIT'NO. ♦.EH11241REv.11ho1 W/ EH 1478 /1 J i i