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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED f (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. �} (SO' loo, Job Address � Kre City Lot Size PM /�y� W o r IL 4(o — qS Owner's Name 1'/57 Y� r� Address Phone 4 Contractor .�, /'l C Qom__ 2:21_icense No. /&� Phare �/ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ 1 +�� PUMP INSTALLATIO�N, N7�� SYSTEM REPAIR ❑ OTHER ❑ + r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ��PROP. LINE FOUNDATION AGRICULTURE WELL ETHER WELL Z121 fi PITS/SUMPS L� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIUry ; ❑ Industrial ❑ Open Bottom47— ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ;I Domestic/Private kCP Gravel Pack ❑ Tracy Type of Casing L Specifications - M Public JJpf1�� F1 Other 71 Delta Depth of Grout Seal Type of Grout - _ I I Irrigation L't' jgq_,�pprox. Depth { 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. �_- State Work Done_ f Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION.1,1 _DESTRUCT-ION I I INo-septic system permitted if public sewer is t available within 200.feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well 't Ubundation ' 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 shalt 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." 1'', The appli 4 all requ' tions. Compfeie,drawing on r ver ide, y Signed X Title:-- � �✓ Date: ,^ FOR1 DEPARTMENT USE ONLY Application Accepted by � Date ` Area os Pit or Grout Inspection by ate 0 U_Final Ens ection b ' _ R Y_. Date_J Additional Comments: 0 (AL1py. ❑•Stk 466-6781 ❑ Lodi 369-3621 a ca 623-7104 ❑ 7(0y 835-6385 App licant- Return all copies to: Environm ntal Heal hPermit/Service 1601 E. Hazelton Ave., P.O. Box 2QW, Stk„ CA 9ra2 i INFO AMOUNT DUE AMOUNT REMITTED CK 0 ASH RECEIVED BY DATE PERMIT NO. r +.EH 13-24 tREV.Iin51 �®s •']y� 'j ; y EH 14-28