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�J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZEL T ON AVE., STOCKTON, CA D \` Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 1 I -/ , �- �� S City Lot Size PM Owner's Name �} ' ��T�i1 �ddrass /�S /?7,�'/y� Phone 6 ✓� Contractor `dress ��b A S'llck S/ License No. 79q7 Phone 313 TYPE OF WELL/PUMP: NEW WELL ❑ WELL TEPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ( 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 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 171 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout _ Ixlrrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work one iFcau rn Well Destruction ❑ Well Diameter Sealing Material (top 50') nl S [ HN R a D/l/= P S L�vv))� ` Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments c PKG. TREATMENT PLT. ❑ Method of Disposal _`l Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line C�. SEEPAGE PITS I I Depth Size Number SUMPS I Distance to heatest: 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 cbun 1 laws, and ( ' rules and regulations of the San Joaquin LocbI Health Di§trict. � � Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which t I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiri (tsu n �9 signature certifies the following: "I certify that in the perforinance of the work for which this permit is issued,1 shall employ persons so ct t0 kr153n i�compensa- tion laws of California." SAN JOAQUIN COUNTY The applicant must call all required inspections. Complete drawing on reverse side. PUBLIC FIFALTH SERVICI`S 8 '�` -' " " Signed X �— Title: Q ENVIR a e EN 1. L 10.4 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by W - D- t-o_ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEbK INFO RECEIVED 8V D TE PERMIT'NO. . EH 1321NEV. -2a EH 14 yL� /