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I ! APPLICATION FOR PERMIT r 1^; �t l t'y t SAN JOAQUIN LOCALJHEALTH DISTRICT 1601 E. HAZE T.ON AVE,, STOCKTON, CA 4 Telephone (209) 466-6781 `+ PERMIT EXPIRES`7,YEAR'FROM`DATE ISSUED'-' 4,. 1., (Complete- Tri lri plicate} .1 ' •.T;L'`;1g tf-� '. ?�, ikF..tr -. `i r r, A C.'ri c 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 Ryles and.Regulations of the San Joaquin Local Health-District: . . „-W •. . _ v . . . IA,* °5z:.ilk L?_ a i4F r .xf. r! A' o Job Address,i l-� . f :c�Cin, '- .'Lot Size PM: w ,.,'s' .6 i Owner's Name� address. �? 7 �-/r—' �r-iGcr F _ Ph6ne3 � < �a- _ ,•_ Contrl�actor � C�4 /" Address -7'�-+�E��L°�� a7� License No,��_ �73 Phone �LI TYPE OF-WELL/PUMP: NEW WELL ❑ I 'WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE v FOUNDATION ' AF3ICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE -AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manter, Dia. of Well Excavation Dia. of Well Casing La-DomesticlPrivate ❑ Gravel Pack ❑ Tracy v Type of Casing Specifications ❑ Public ❑ Oth4 ❑ Delta .� Depth of Grout Seal Type of Grout ❑ Irrigation 1 �4pprox. Depth ❑ Easterr)' Surface Seal Installed by Repair Work Done i� Type of Pump 's r H.P. _-_ State Work Done Well Destruction ❑ Well DUrneter Sealing Material (top 50') - `� i Depth Filler Material (Below 501 l\ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ..7-..,. . available within 200 feet.) Installation will serve:' Resident — Commercial�} Other If Number of 9 livin units: umber of bedrooms 1 r . r Character 6f,soil to a depth of 3 feet: I ; Watetr ble depth SEPTIC TANK ❑ Typ /Mfg ! Capacity No. Compartments PKG. TREATMENT PLT, ❑ ! Method of Disposal 1�4 1 Distance to nearest: Well Foundation Property Line LEACHING LINE -❑ No. kt! Length of lines fi c `Ul. Notal length/size E FILTER BED ❑ Distalnceto' nearest: Well__ Foundation' " Property Line SEEPAGE PITS:of O 'Dep II `it- `+ Size ". � - �'7 T'� Number SUMPS ❑ Distance to nearest: Well'- -Foundation Property Line e DISPOSAL PONDS ❑ 1-hereby-certify-that-I-have-prepared-this-application-and-that•.the-work-Will-be-dote-in-accordance-with-San Joaquin`countycfrdinances-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 manner as to become subject to workman's compensation laws of California."Contractor's 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." f The applican tcal for all req 'r�lnspec,-ont. Completedrawing on reverse side.Signed X. Date:y'V'�fitle: "� 0- FOFi EPARTMENT USE ONLY Application Accepted by Date . Area k Pit or Grout Inspection by Date Final Inspection by t &xl Date Additional Comments: ' i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental'Health Permit/Services 1001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE ,+ AMOUNT REMITTED - CASH RECEIVED 8Y. DATE PERMIT`N0, a + EH 1324I REV.1/s 51 •�. f/' - EH 14-26 / p r.- ' '- ` fC/9