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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,'STOCKTON, CA -Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR-FROWDATE ISSUED (Complete in-Triplicate) t 4r'` 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 Ryles and Regulations of the San Joaquin i Local Health District. 40 ] �• Job Address /-72 72 _ Cd City l Lot Size PM Owner's Name d 5s��✓de,�1r� Address T 2_/ ?G Z LS 14PP0V-oy kph�o e Contract e��" ''L / ddress /-•Lf. �X ��License No. 2- 2- Phone �' p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR.0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrials' '-E] Open Well Excavation--- - Dia.of Well Casing 1111 ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �Q ❑ Irrigation --Approx. Depth. ..❑.,Eastern Surface Seal Installed by \ \ r Repair Work Done ❑ Type.of pump_. H.P. State Work Done E Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ,(No septic system permitted if public sewer is i * available within 200 feet.) Installation will serve: Residence_ Commercial_ Other r i Numbe�rof living units: Number of bedrooms Character of soil to a deptkof 3 feet: Water_table.depth - SEPTIC TANK D `rType/Mfg Capacity No. Compartments j PKG. TREATMENT PLT..Ll Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. &'length of lines Total length/size FILTER BEDI ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size = Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line r ' DISPOSAL PONDS ❑ I hereby ce fy 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 redulations of the-San-Joaquin Local-Health-District.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." Contractors 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 applican must call for all squired inspections. Complete drawing on�reverse �side. Signed Title: Date: FOR DEPARTM T USE ONLY Application Accepted by Date 41Area Pit or Grout Inspection by Date Final Inspection by ' Date —Z - J` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ` Applicant-'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Av-e., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED f0C SH RECEIVED BY DATE PERMIT'N0.' +EH1&241REV.1/B5) EH 14-26