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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` - (Complete in Triplicate) 1 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 and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1 City Lot Size j PM 3 Owner's-Name Address - phone r Contract r AddressR-01 7-6 7 License (lo, hone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE {' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL ?RQLEM AREA , CONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca 1�Dia. of Well Excavation- r Dia. of Well Casing Al i El ❑ Gravel Pack ❑ Tracy r Type of-Casing-�n—•' f7PC#%C-- n-Others`-— Specifications Depthof-Grout-Seal- I t ------ Type-of-Grout-- I Irrigation --Approx. Depth I I Eastern Surface Sear Installed by Repair Work Done ❑ Type of Pum - � Yp p H.P. � State Work pone_ Well Destruction ❑ Well Diameter Sealing Material (top Depth Filler Material f Balow 50:1. TYPE OF SEPTIC WORK: NEW INSTALLATION . REPAIR/.ADDITION i'l—DESTRUCTION`( l (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:- Residence Commercial_ then- e, J Number of living units: .,. Number o ooms Character of soil to a depth f 3 feet: r�• Water table-0 th + � 1 SEPTIC TANK 4� Type/Mfg f C � a acit mp P y _No. Compartents PKG. TREATMENT PLT. O j r Method of Disposal Distance to nearest: Well Foundation�42_ Property Line , LEACHING LINE t/r' No. & Length of lines ZOO � Total length/size F1FILTER BED Distance to nearest: Well ZOO Foundation-�"— Property 'I SEEPAGE PITS 14—"'Depth Size Foundation Number i SUMPS D Distance to nearest: Well [ Fo ' DISPOSAL PONDS ❑ Property Line _ 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 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 mu all for all q ired inspections. Complete drawing on revs 10 e- Signed X Title: R �I Date 7 R DEPARTMENT USE ONLY Application Accepted by �1 I Date1 'r _$F Area P. r Grout Inspection by ate Final Inspection by -r2 f Date Additional Comments: El 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 FEE AMOUNT DUE AMOUNT REMITTED II INFO y� CASH RECEIVED BY DATE PERMIT-N . + EH 13-29(REV.1/n 5f EH 14-28 �