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APPLICATION FOR PERIMIT OPSAN_JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 / cl? yd'4 ggqq 11,ys City Lot Size PM Owner's Name P_ SSS Address 1X5— Phone Contractor Address 3 cense No- zi Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION R AVSr} tW-2 r '+y � PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G7"1yWVJ A A S A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 'r FOUNDATION AGRICULTURE WELL -_5 - OTHER WELL t; - PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation-770'd f'2 " Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 41 f pyel Specifications I'1 Public n Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 5tate Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') ° Depth Filler Material (Below 501x ' TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION/IDESTRU CTION I I INo septic system permitted if public sewer is available within 200 feet.) t 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 i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal r, Distance to nearest: Well un dation Property Line LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: ell_ Foundat n Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS L1 Distance to nearest: Well.__ Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this app�ilfie�s ion and that the work will be done in accordan with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Loealth District. Home owner or licensed agent's signature ca- the following: "I certify that in the performance o e 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 call required ins tions. Complete drawing on reverse side. f�l/tdp_ Signed X�I�1 wf�a J Title: ?Z-f 1✓ail Date: OR DEPARTMENT USE ONLY Applicationccepted by Dv- :�fC e1 \ ate_ Area_ Pit or rout spection by -, C Data 46 Final Inspection by Date �1 Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 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 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EH 13.24(REV.I/x Sl t EH 14-26 j�.1 ,%�� <' �� 2.��i ! /O- :��C