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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA f 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin k Local Health District. Job Address ©olef City -40tot Size 5/1' PM � Owner's Name _gz _ �-I`7r� Addr s 4_�� Phone 7_`'' �— Contractor Address � License No3O`_�72/ Phone 34 A. .-?_; TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ► FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f l Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout— l I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done IJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is Iavailable within 200 feet.) Installation ill serve: Residence 00"' Commercial_ Other Number of /Irving units: _L_ Number bedro ms � 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 r Distance to nearest: Well a f Foundation /6 r ProIilerty Line LEACHING LINE L�Na. & Length of lines (Total length/size ttt FILTER BED ❑ Distance to nearest: Well 640 Foundation:f�/�9 -� Property Line d SEEPAGE PITS 44" Depth s r Size # w ! 'Number SUMPS LIDistanc a to nearest: Well 'SO'!+ foundation / f p �f._..� Property Line DISPOSAL PONDS El - / 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,Di`t"rlCt. , 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 td4ecome subjetl to workman's compensationJaws.of_California,"�Contractor's hiring or sub-contracting signature certifies the following: "I certifytha`t in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." 41—i The applicant must call fpf al requiredataspections—Complete`dr�Wing on reverse side. +? � I Signed X_ - ("':Title: e fig' Date: FOR DEPARTMENT USE ONLY �t Application Accepted by date it r Grout Inspection by-7d Date ^ Final Inspection bol �`� D t - 4 Additional Comments: C3Stk 466-6781 LI 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 AMOUNT DUE AMOUNT REM'TTO K INFO (RECEIVED BY DATE PERMIT'NO. € f! EH 13 a EH 1428'24 '/13/ 1 4IREV.I/K5) V 3 'te l