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.. �_ f APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE.,;STOCKTON CA Telephone {209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED 1 i (Complete in Triplicate) ,, I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal!the work herein described. This application is r 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. ' •:. ;� .. '�:, � 't-.:� iii" i' - .. .. Job Address iA. 5-fi A, r "' `•�� /f� e 9 jnC�ity O C Lot size `t't// PM Owner's Name�J i✓.} : ` 1._i .C/� y Sa'`/ �6[ "�`��5��-� Address 'Cy' C( -f Phone � } Contractor OC.ft C \Od�T f t y f� Address icense No.4315-72-Z. Phcne L�4'S TYPE OF WELL/PUMP: ;NEW WELL ❑ WELL FIEPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR-❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES I ,,� € : t ' ' ` DISPOSAL FLD. PROP. LINE FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE W - -TYPE OF-WELL PR06LEMAREA7 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing :...- ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing "t ( 1 f + Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ' 1 ❑ Irrigation Type of Grout --Approx. Depth 11Eastern Surface Seal Installed by a Repair Work Done CJ Type of Pump H.P. State Work Done Well Destruction Well Diameter T�r r Q Sealing Material {top 501) f/Z �c'(J { p Depth Z Filler Material (Below 50') J G TYPE OF SEPTIC WORK: NEW INSTALLATION ❑: REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is x Installation will serve: Residence_ Commercial available within 200 feet.)i Other Number of living units: Number of bedrooms j t Character of soil to a depth of 3 feet: T` 46 Water table depth - f" SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑` No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation—-_'Property perry Line SEEPAGE PITS ❑ Depth •.. Size Number SUMPS ❑ .Distance to nearest: Well DISPOSAL PONDS El Foundation Property Line w f 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 s 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 em to tion laws of California." P�Y Persons subject to workman's compensa- The applicant fust call.for all requFr d i spectioris. Complete drawing on reverse side. j k� Signed X Title: r Date: � FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by, :;*� Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621,, ❑ Manteca 823-7104 ❑ Tracy 835-6385 Y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.;CA 95201 FEE INFO AMOUNTrOUE I AMOUNT REMITTED K RECEIVED'BY C DATE PERMIT N6_ �.-+ EH 1324/REV.5 i A W "f - �.. I y: .a r EH 14-26 " ._. 1 O .6