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r r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA a 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. Job Address lf��% -- City Lot Size tiLL PM Po , sex 1,3 9 N�M_t � Address hone I Owner's Name �- i z�'z I Contract Address License Na.3 26 Phone 1` TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �- INTENDED USE TYPE OF WELL F PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Industrial '❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications €"1 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout 1 ) Irrigation --Approx. Depth I I Eastern Surface Seat Installed by — } Repair Work Done ❑ Type of Pump H.P. State Work Done= J Well Destruction --- -❑ Well Diameter Sealing Material.(top 501 -- Depth er Material lBelow 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION I.3REPAI /ADDITION DESTRUCTION I 1 iNo septic system permitted if public sewer is _ I ;, ; _i available�ithhirn,2@0 feet.)n�e+cttr.Q) Installation will serve: Residence Commercial � Other r � Number of living units: Number b rooms ?,r I Character of soil to a depth of 3 feet:_ ara.t/� Water table depth V SEPTIC'TANK ❑ Type/Mfg Capacity : No. Compartments PKG.TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation Property..Line LEACHING LINE ❑ No. & Length of lines Total iength/size FILTER BED ❑ Distance to nearest: t : Well Foundation Property Line a r " ti SEEPAGE PITS Depth S Size r�` Number' umber S l - SQ' _.Q., _ . SUMPS ❑ Distance to nearest: Well Foundation- Propertyine t DISPOSAL PONOS ❑ r 1 6e'eby 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-arid 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." 1 The applicant mu it for all ui d'inspections. Complete drawing on reverse a:' Signed X ti ' Title: Date:,�� FOR DEPART_MENT.'USE ONLY A ication Accepted by �' 3 Date f Area 3 Pit r Grout Inspection by ata 7 Final Inspection by". Date' Additional Comments: ❑ Stk 466-6781 Cl 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 \91 FEE AMOUNT DUE AMQUNT REMITTED CASH RECEIVED BY PATE PERMIT' INFO NO r•EH 13-24(REV.t/n 5) -9 EH 14-28 p g