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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 Local Health District. ' CitLot Size Job Address y zPM�./ P`rj Owner's Name AddressSk2Z!A,_ Phone / 7 / t dreContractos`s 1< WI -1.�AaLicens:0 No. Kil n Phanef TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE ACEMENT ❑ DESTRUCTION ❑ 1 f PUMP INSTALLATION ❑ S TEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK 5E R LIN QISPOSAL FLD. PROP. LINE r FOUNDATION AGRI L URE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS CI Industrial , ID Bottom ❑ Manteca Dia. of Well-Excavation ----�� Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing r r Specifications i`l Public ❑ Other F Delt Depth of Grout`Se-al I Type of Grout _ I Irri ation A 1 g' _. pprox. Depth I 1 E tern Surface Seal Installed by - I Repair Work Done (] Type of Pump f H.P. Staie-Work,Done_ I \ Well Destruction r]- Well Diameter Sealing Material (top 50') t I +Depth Filler Material lBelo ) ) n TYPE OF SEPTIC WORK; NEW INSTALLATION I'I REPAIR/ADDITION V DESTRUCTION i I (No septic system permitted if public sewer is 1�v\ r L- ---� available within 200 feet.) V Installation will serve: Residence Commercial Other (t 1! # Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ? �n'_"""'Water tall depth SEPTIC TANK ❑ Type/Mfg Capacity_.!•2UQ `_"_No. Compartments PKG. TREATMENT PLT. ❑ �y.r. A bi ..Method of sposal ; y . .'- ' Distance to nearest; Well Foundation Property Line LEACHING LINE ❑ No, air Length of lines ` To I length/siz �Line FILTER BED ❑ Distance to nearest: Well f oundation d. , �k Property SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well t� Foundation I 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 taws, and rules and regulations of the SanrJoaquin 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 wtiichYhis permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I I The applicant19 st call for all ired rations. Complete drawing on reverse side Signed X .- .. Title: - Date: J k^2 /rl s "S. T OR DEPARTMENT USE'ONLY Application Accepted by ' para �Area Pit or Grout Inspection by f Date Final Inspection b Date 7 Additional Comments: )afl LI Stk 466-6781 ❑ Lodi -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 CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH EH -2e --70.0o 1324fpEV.tin51 t1 l