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,. APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 1 (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. I I Job Address 2t ' City Lot Size PM k ' Owner's Name /" �L ddress _ Phone . `� e Contractor l Address f A�XI - License No,.94:95M/Phone TYPE OF WELL/PUMP: NeW WELL WELL REPLACEML7NT ❑ DESTRUCTION ❑ PUMP INSTALLATION_V1 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 SPECIFICATION S ,P Ll Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casi Abomestic/Private 1mravel Pack ❑ Tracy Type of Casing Specifications [_1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout a I I Irrigation aQnApprox, Depth l I Eastern rface,Seal Installed by T Repair Work Done 0 Type of Pump _./J H.P. Z-4 - ----State WCrrk'pgrie _ I Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material IBelow 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I 1 lNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_} Commercial_ Other k Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well F6-undation 't Property Line I k ' SEEPAGE PITS l 1 Depth Size —.Number j SUMPS L1 Distance to nearest: Well Foundation f'Pioperty 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 Di3trict. 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 i employ any person in such manner as to become subject to workman's compensation.laws:of,"alifomiaContractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued;i-sF all employ persons subject to workman's compensa- tion laws of California." The applicant ;r al requir i s. Complete drawing on rave reg side. �ASigned X Title:�� Date: , I FO DEPART40 MENT USE;O LY""° Application Accepted by Date Araa Pit or Grout Inspection by �' Date S 9 L� Final Inspection by DataOle Additional Comments: Q�/1^+/✓ er l-I' : r �S _ 0 Stk., 466-6781 ,.❑ Lodi_369 3621 - ❑.Manteca 823-7104,. �--0-Tracy -835=6385 �--�� ---'^ ^-" /]U�Ji Applicant- Return all copies to: Environ/mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo 009, Stk., CA 95201 `f I 1 FEE AMOUNT DUE AMOUNT REMITTED 3 CAH RECEIVED BY DATE PERMIT•NO. INFO CAS +.EH13-24(HEV.1iNSi �C)S ,L Z3 EH 14-26 a Z I F