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t t- APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA r � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��L, / IAP (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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- '-9 I Job Address _5"o . N/ �-i�G�to /_A) City X&DC7 PV- Lot Size PM Owner's Name F�if��GiSC 0 '.&IWA14 Address 3 So. W ALK� - ___- Phone Contractor �� Address la,/P7 t. License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUItimP'INSTALLATIw❑' `" SYSTEM REPAIR-LT -"'OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Fl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx.+Depth l I Eastern -Surface Seal installed by- Repair Work Done ❑ I Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material flop 501 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l ) DESTRUCTION03- INo septic system permitted if public sewer is available within 200 feet.1 + Installation will serve: Residence Commercial_ Other Number of living units: Numbj r of bedrooms Character of soil to a depth of 3 feet: I Water table depth r SEPTIC TANK ❑ Type/Migi _Capacity -_ v—No.Compartments PKG. TREATMENT PLT.'❑ Method of Disposal kz t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 'O—Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LT„_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 Doltrict. 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." Contractors 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 mus call for all required ins ctions. rpmplete drawing on reverse side. Signed X�JL�i.►..a4t � � 5 Title: _ wNt /e t Date: 7 3 " F EPARTMENT USE ONLY Application Accepted by ` Date Area Pit or Grout Inspection by t Date Final Inspection by Date 4 7 _ Additional Comments: _ �W4 __ F1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 W Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE 1 AMOUNT'REMITTED CASH RECEIVED BY DATE PERMIT'NO. a-EH 1 -24 iREV.t K 5l �� 21, L�A'7 . _ _ r� EH 144-28