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x 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 LJ�-- (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. p x Job Address _ �► .e pifil *City Lot Size /SCI 7( `26 _ PM i Owner's Name Address - Q Phone r Contractor Address 17 License No. Phone a 3F TYPE OF ELL/PUMP: NEW WELL C3 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Wefl Excavation Dia. of Well Casing ` Specifications ❑ Domestic/Private El Gravel Pack ❑Tracy � Type of Casing pe El Public ❑ Other L] Delta ,,t..,,Depth of-Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.P. State Work Done G Well Destruction LlWell DiameterSealing Material (top 501 Depth J Filler Material (Below 501 ` Q TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ;REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) V1 f. Installation will serve: Residence j Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well i Foundation Property Line LEACHING LINE ❑ No. & Leng3h of lines! Total length/size FILTER BED ❑ Distance to'nearest: Well ► Foundation Property Line SEEPAGE PITS ❑ Depth it'd Size Number ` r; SUMPS C1 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,�ccordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. .1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this per is issued, I shall not employ any person in such manner as to become subject to workman's.compensation laws.of,Cal'rfornia."Contractoes 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 must call for a requireh inspections. Complete drawing on reverse side. Signed Title: 4/ — !/ Date: �.i o FOR DEPARTMENT USE ONLY ' 3 J__- ... �,.-�...4..�.•-.�,.•-:.�._.,.,�te Area Application Accepted by Pit or Grout Inspection b Date Final inspection by r Date + Additions! Comments: .� - `_ � �� I �•4 -� - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantece_823-7104_._O.Tracy _935•6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIt`NO. INFO .�Q(y / �7 + EH 13-24(REV. 85) [' ��. bO �Z�S r IC7`� f. '`4617 EH 1428