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p� 40a- f y` t APPLICATION FOR PERMIT { SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA�ELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N. y (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 r Local Health District, ` Job Address Lot Size Z&2nf� -Q- PM a /] �J T Address �� Gt�X�� Phone ! �a t Owner's Nam LG1iYt.( l� V �_ �- _�1 Contract Address {"gip• 10X �(e� r�(�License No.17-727Z fe Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER C 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 ❑ Industrial C open Bottom C Manteca Dia_ of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack C Tracy Type of Casing_._ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout E Irrigation __Approx, Depth O Eastern Surface Seal Installed by-- Repair y _.Repair Work Done , Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing',Vaterial i4op Depth /ler Material {Bela .50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /ADDITION DESTRUCTION 13%(No septic system permitted if public sewer isv�/y�+ �r available within 200 feet.) V,1 Installation will serve: Residence� Commercial_ Other v i Number of living units:�_ Number of b droomFs Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity Y -No.Compartments t PKG. TREATMENT PLT, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE V,-No. & Length of lines Total length/size V FILTER BED C Distance to nearest: Well !G�n Foundation / Property Line SEEPAGE PITS Depth %ZS Size— - �i �—Number_ SUMPS ❑ Distance to nearest: .Well FoundationProperty Line __ C + DISPOSAL PONDS C] I hereby certify that 1 have prepared this application and that the work will be donejrn 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: "V`ertify that in theperformance 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." The applicant must call for equ'r d inspections. Complete drawing on rave de. \ jt y� r . Signed X_ T-rde: Date: :FOR DEPARTMENT USE ONLY Application Accepted by ��c Date Area / A)-, Grout Inspection by Data _ -Final Inspection by b G Additional Comments: _ - /Y C Stk 466-6781 ❑ Lodi 369-3a21 ❑ Manteca 823-7104 Tracy 835 63»✓ _Applitant_Retufn-all copies-to. Environmental_Health-P-ern-WServices..1601-E._Hazelton-Ave.,..P 0.-Box 2009,FEE -Stk.;-CA.9fi201------,----- - a INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED RY DATE PERMIT NO. + EH 13.24(REV.1/H 5) L jIVI �4 EH 14-28 . .7