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T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 j PERMIT EXPIRES T 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 V r oq C I f,,Iaey City Lot Size PM Owner's Name �1 N-17 Address Phone' 4 C 'Ci7ritfa Etor-, - - CO -- ----Address'- -`` C - L�icense•-No: --.Phone-- -? 1 f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE --- --.-.,_.- FOUNDATLON_ 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 ❑ Domestic/Private' C} Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public f7 .Other ❑ Delta Depth,of Grout Seal Type of Grout I I Irrigation _.._-Approx. Depth I'1 Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of PumpH-P--- - — State Work Done Well Destruction ElWell Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1. TYPE OF SEPTIC WORK: NEW INSTALLATION IT REPAIR/AUDITION l_ RUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence commercialOther c Number of living units: Number of edrooms� m Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK hype/Mfg s 0 Capacity_(__ No. Compartments PKG. TREATMENT PLT. ❑ - Method o Disposal Distance to nearest: Well S�_ Foundationr Property Line r ;fl LEACHING LINE &I—ITo--8t Length of lines "Total length/size FILTER BED ❑ Distance to nearest: Well Foundation iProperty Line k. SEEPAGE PITS C I epth Size 3 ' Number SUMPS 0 Distance to nearest: Well Foundation Property Line S 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. til., 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 certif' s the following: ', 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 California. lk T. a applica t m call for fl re fired spe on �mplet�edrawing�o reverse de. Signed Title: Date: r-2O a FOR DEPARTMENT USE ONLY n i Application Accepted by ' Date Area F Pit or Grout lnspectio by Date* Final Inspection.by Date Additional Commerrfs: 7 1T ""'�`� Q le- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 S 4 y FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE EPERMIT'NO. INFO CASH+ EH 13-21 tREV,iiH5l '7-1-0 �^ �� EH 14-28 �ia y 1