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APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE. STOCKTON CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .." , AXI i c (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 arid the Rules and Regulations of the San Joaquin 'y Local Health District. { t}� Job-AddressCity r ize PM�f Owner's Name Address ��'O fJ�J7`Z.�_ Phone Contractor ss icense No p v Phone TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ; INTENDED USE TYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1:1Industrial, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing lq_> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Q i Repair Work Done ❑ Type of Pump H.P. State Work Done ; Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 'r.,` r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is i available within 20O-feel.) r ' Installation will serve: Residence v Commercial_ Other Number of living units: __L._ Number of bedrooms,_ ✓ . . . Character of soil to a depth of 3 feet: _ � �� x Water table depth ' } SEPTIC TANK ❑ Type/Mfg ~Capacity 'IVo Compartments PKG. TREATMENT PLT. ❑ w—^m w' Method of Disposal , l Distance to nearest: eiV1l I Foundation Property Line J LEACHING LINE No. & Length of lines !'� Total length/size FILTER BED ❑ Distance to nearest:. .,Well Foundation Property Line I r SEEPAGE PITS Depth Size Nu fiber-- r f ' SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. 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." f/ The applicant rrwst call for II req ed Os tions. Comp to awing on er side. " Signed X -.Title: Date: FOR.DEk.PART ENTUSE ONLY G Application Accepted-by ,- � r Date � Z� -"a Ar r 15/Grout Inspections by Date Final I'spection by Date �� >� r � _ � 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 Ave., P.O. Box 2009, Stk„-CA 95201 `sa INFO, AMOUNT DUE c AMOUNT REMITTED_ ASH CK RECEIVED BY DATE PERMIT NO. EFF 14-4 1pEv. ,H 5, - }. .15. EH 14-2a