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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 EXPIR69`i YEAR FROM DATE.ISSUED ate. (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. Thistapplication 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 C:4' *`s].t City Lot Size PM Owner's Name Address .. C 1 r lrC GY. Phone SW Contract 4-- 4:'d !- -� Address License No.3 Z1�Z 24 Phoned i TYPE OF WELL/PUMP 1wNEW WELL 1-1F--WELL REPLACEMENT❑ ' DESTRUCTION ❑ ? } PUMP INSTALLATIOd,❑r ' SYSTEM REPAIR ❑r OTHER EJ DISTANCE TO-NEAREST: SEPTIC TANK � +''SEWER LINES` - -DISPOSAL FLD. PROP. LINE / ^.� `FOUNDATION ' AGRICULTURE WELL OTHER. WELL PITS/SUMPS I 'INTENDED USE TYPE OF WELL ` PROBLEM AREA CONSTRUCTION SRECIFICATIONS A ��` f ❑ Industrial ❑ Open Bottom ❑ Manteca y;. Dia. of Well Excavation Dia. of Well'Casing t , ❑ Domestic/Private ❑ Gravel Pack r ❑Tre6y Type of Casing Specifications y ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx., Depth k❑ Eastern , Surface Seal Installed by r ` Repair Work Done ❑ Type of Pump 3 Dr H.P. Statee Work Done Well Destruction ❑ Well Diameter' s 'T Sealing Material (top 50') * / �` � Depth : �A- Tiler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL•LATIONIIT /ADDITION Z- DESTRUCTION ❑ (No septic system permitted if public sewer is "available within 200 feet.) v Installation will serve: Residence,, Commercial_ Other Number of living units:1`- Number of begdrqoms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ T Water table depth Q e/Mf r YP 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: ni WellFoundation 'Property Line . I LEACHING LINE ❑ No. & Length of lines l r� r Total length/size FILTER BED ❑ Distance to nearest- Well Foundation +Property Line 1 i SEEPAGE PITS ❑ Depth ,_Size Number SUMPS R�'Distance to nearest:- i Well Foundation /,p `Property Line_�45' DISPOSAL PONDS ❑ # ` M I hereby certify that I have prepared this application and that the work will be done in accordance with kSan 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 workrnan.s.compensaii&n 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 st call for all req ired inspections. Complete drawing on reverse side. Signed X Title: Date: FOR;DEPARTMENT USE ONLY a y t � Application Accepted by �T Date Area f�n ` I ` G�fS f t Pit or Grout Inspection bye/ pate F na Inspection by `Q Date Additional Comments: i ❑ S5 -466 6781 Lodi 3697621 ❑ 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 / a FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y" DATE PERMIT'N0. INFO CASH tN 1324+REV.riHsl -70. 0z `.i".. [�` R'!�i— 3