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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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. 1662 for weillpump and the Rules and Regulations of the San Joaquin Local Health District.. +� Joh Address ! City 014 CV. Lot Size PM , Owner's Name dresst Phone_ Conti-actor t9� 1` rya® ^ Address License N . i TYPE OF WELL/PUMP: NEW WELL El WELL. REPLACEMENT El DESTRUCTION ❑ I PUMP INSTALLATION D SYSTEM REPAIR ❑ OT Fla-L-3--- DISTANCE TO NEAREST: SEPTIC'TANK'-.. SEWER LINES,' _�] L FLD. PROP. LINE r FOUNDATION 2 AGRICULTURE OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL',. '•. rPROBL A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ DomesticlPrivate ❑ Gravel P =❑'Tracy^ _ Type of Casing Specifications I 1-1 Public [7 Other f 17� Delta Depth of Grout Seal Type of Grout - I 1 Irrigation _Approx. Depth l l I Eastern, Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 50') Depth k Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION K DESTRUCTION l [No septic system permitted if public sewer'is I available within 200 feet.) Installation will serve: Residence Commercial_ her IN,� 1.L fY4f W /� I , Number of living units: Numb��ofbedroomse �� Character of soil to a depth of 3 feet: IP ',A�y Water table depth SEPTIC TANK `1 X Type/Mfg 1 CapacityP� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well SO / Foundation�._— Property Line ___— r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l'I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line R 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. 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 i ch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followi g:'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 Calif ni The applica call for requir drawing on reverse side. Signed X Title: Date: —.21 r FOR DEPARTMENT USE ONLY ` r7 �7 Area f ` � Application Accepted by Date 2 / Pit or Grout Inspection Date^ a spection by Date S Additional Comments: ❑ Stk 466-67816 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk.,'CA 95201 FEE. AMOUNT DUE AMOUNT REMITTED CK RECEIVED 6Y DATE PERMIT'NO. 1 NFO {1_ CASH + EH1124JREV.1/Kb) -70 , o l EH 14-26