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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT iyp� 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED H.tn,, (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 No.5 made in compliance with San Joaquin County -Ordinance N49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District: '1; Job Address 53 0 2 `' (� 2 I. �v��rtt ,:6 ?�!ZO J r Q. City_1 ,p ,(Xt Size- e PM �( Owner's Name dress _7 S L J IL p /2(�t Phone 4662 V rY Contractor Address' License No.-Phone--.- TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT E1 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private D Gravel Pack ❑ Tracy Typeof Casing - - ' — £ Specifications tions ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx.IDepth O Eastern Surface Seal Installed by ; e Repair Work Done ❑ Type of Pump z H.P. State Work Done_ Well Destruction ❑ WeII Diameter Sealing Material (top 501 Depth I Filler Material-IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION.� DESTRUCTION (No septic system permitted if public sewer is I �� `�` '' '' : available within 200 feet.) Installation will serve: Residence (Commercial_ Other Number of living units: Number of bedrooms + r Character of soil to a depth of 3 feet: ° Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 4 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑' No. & Lengtil,o�f.'lines Total Iengthlsize. FILTER BED L-] Distanceto nearestt:' Well Foundation Property Line SEEPAGE PITS " ❑ Depth I :Size Number SUMPS ❑"..Distance to nearest: Well t 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 county ordinances, state laws, and rules and regulations of the San Joaquin Local Health-District. f 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 subjeci•to:workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of ih"e work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r The applicant mu f al�quired inspe tions. Complete drawing on reverse side. y� Signed X M6: f if Date: oZ O (�y��,,\,{f\��f(1�� FOR DEPARTMENT USE ONLY Application Accepted by ' ` 4 V t, Date a Area v I Pit or Grout Inspectio t bate./ Final Inspection by Date Additional Comments:" 4 13 nN� 1VQ ❑ Stk- 466-6781 Lodi 369-3621 71Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO "'AMOUNT DUE r; AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. EM 13-24 i EH 14-28)REV.t i H sJ + �...]. Q'� Cr] - � ` Z/