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i APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA l Telephone (209) 466-6781 r 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 mo::k, . � �2_1x1 1!c City +-J Lot Size M I Owner's Name ( Addressq CCX_�r( ,t,,4t r— r d-_.. Phone 4 Contracto'm 1 1 Ekc Address 03 t License No. 35-C)¢ gPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.$`, . ' F SYSTEM REPAIR ❑ - OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I f DISPOSAL FLO. 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 Dia. of Well Casing 6LDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public P.Other I--] Delta Depth of Grout Seal Type of Grout _ I i Irrigation __---.Approx. Depth l I Eastern Surface Seal Installed by } - Repair Work Done ❑ Type of Pump W.P. State Work Done 0 , Well Destruction ❑ Well Diameter rte— Sealing Material (top 50') �S Depth �r Fillet Material (Below 50') _ I TYPE OF SEPTIC WORK: NEW INSTALLATION ('1 REPAIR/ADDITION I I DESTRUCTION l I Wo septic system permitted H public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other' k ' Number of living units: Number of bedrooms , Character of soil to a de th of 3 feet: w.. P Water table depth SEPTIC TANK ❑ ;.Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal -� IDistance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Well fi Foundation Property Line SEEPAGE PITS l I'�•Depth' ' Size r ' Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Nom„ t / f ' 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 I t rules and regulations of the San Joaquin Local Health Di"strict. + Home owner or licensed ' a ents signature certifies the following:g 9 g: "l 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 California.." The applicant st call for all r uire ins tions. Complete drawing on rave se side. Signed X Title: Date: e F. DEPARTMENT USE ONLY Application Accepte by4 -k Data - ^ Area Pit or Grout Inspection by Date Final Inspection by Date 2-Z 6, -td s '^ Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ♦.EH t3-241REV.i/xslr•,� / 0... �/ EH 14-29 r1J-0 W I f