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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I . 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone 1209) 466-6781 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 9 /c G 2✓J 204--b370C-X7AAJ /UOX j 33CityLot Size PM 3' Owner's Name S7— �C 5 e C.L Address /L LO Phone Contractor Address License No. Phone TYPE OF.WELL/PUMP: NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing' Specifications ❑ Public r ❑ Other ❑ Delta Depth of Grout Seal ' Type of Grout ❑ irrigation -__Approxi Depth ❑ Eastern Surface Seal`Installed by Repair Work Done L2Type-of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top..50') t Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is + available within 200 feet.) Installation will serve: Residence_e Commercial_ Other Number.of living units: --/-- Number of bedrooms ' Character of soil to a depth of 3 feet: r Water table depth y� SEPTIC TANK ❑ Type/Mfg!.' Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,y Method of Disposal tl Distance,to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines C.-_ : g Total length/size FILTER BED ❑ Distance to nearest: Well Foundafion"""' - Property Line I 1 t SEEPAGE PITS ❑ Depth Size 1 Number SUMPS I ❑ Distance to nearest: Well . 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. , 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 employ persons subject to workman's compensa- tion laws of Ca mia," 1 _ The applican _.,tcall for all re fired omplate drawing on r arse side. , Signed Title: Date: 1 a I FOR DE ARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by bate Final Inspection by .r'^I Date A ditional Comments: � Stk 466.678.1_ —p-Lodi 369-3621 .,❑.Manteca—823=7104>--❑"Tracy'"835M%— z licant- Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE i f� t INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT"N0. '1 ✓ 1 C * EH I1REV.1/851 W29 ♦ `� k 5. cac 575 qjr , -- 193 J i