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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 (Complete in Triplicate) Application is he♦eby 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. 1 Job Address 522 1 /,f � Al / _ City Lot Size P• ,"pM Owner's Name Nf4.101 fV . !��•r f _ Address � /� a 7�,yJ >D Phone Contractor Address License No Phone_ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMEN ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 4&ej 1 SEWER LINES DISPOSAL FLD. PROP. LINE �` \ FOUNDATION AGRICULTURE WELL -140 r OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing leyC ` f"1 Public C7 Other Specifications ��o \.. ❑ Delta Depth.of Grout Seal �M �Typaof Grout �oh,�,y. I i Irrigation .3e&.Approx. Depth I ] Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump S-1-4-4 H.P. - State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 -Depth- ----_ A, Filler,Material.I Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial` Other f available within 200 feet.) , Number of living units: Number of bedrooms ! Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth Q Type/Mfg PKG. TREATMENT PLT. L7 Capacity No, Compartments ' Method of Disposal Distance to nearest:, Well Foundation Property.Line LEACHING LINE ❑ No. &.Length of lines Total length/size FILTER BED ❑ Distarice to nearest: Well' {r } Foundation Property Line SEEPAGE PITS I I Depth- Size I Number SUMPS CI Distance to nearest: Well Foundation DISPOSAL PONDS 13 Property Line I hereby certify that I have prepared this application and that the work will bedonein accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di$trict. 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 which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must r all req inspecti o to drawing on reverse side Signed X Title:- Date" FOR DEPARTMENT U ONLY Application Accepted by Z j /Q Date Are n�Fina! Inspection by Date_Z� Pit or Grout Inspection by Date i"` f-sl r } Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED , CK INFO CA H RECEIVED BY DATE A PERMIT'NO. +.EH 14-Ze(REV.7 i x 51 l� ,Jr f! d�) ��P. .