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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r 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 installthework 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 I Local Health District. j� v Job Address City_:5 Eo Lot Size PM 17E��, � - Owner's Name J ddress Phone Contractor ��1�I9� 5 a •_Address License No. "rrd0 Phone TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A, -,_ SYSTEM REPAIR ❑ /OTTHHFtR ❑ DISTANCE TO NEAREST: SEPTIC TANK �/ SEWER LINES --- DISPOSAL FLD.� PROP. LINE FOUNDATION �� "." AGRICULTURE WELL �� OTHER WELL- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j( ❑ Industrial ❑_Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ot:-_ Specifications Cg/ F] Public ❑ Ot rer Cl Delta Depth of Grout Seal < Type of Grout_&�J I I Irrigation Approx. Depth l I Eastern Su ace Seal Installed by. Repair Work Done ❑ Type of Pump H.P. State Work Done \ Well Destruction ❑ Well Diameter Sealing Material (top 501 m Depth Filler Material IBelow 501 �} TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial____ Other + Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth .SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 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 ❑ 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 D(ktrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the.wor :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 Co ifactor''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." i The applican i. �r II.re i ctions. Complete drawing on revers side, j ,7W1611esp l Signed Title: ` { - Date: sr FOR DEPARTMENT USE ONLY /u Application Accepted by Date r Area_0 C lnspectioPit ote Final Inspection by v p .Additional Comments: We kU U t 2 Le, f -,1"- l Srn l� (-YU►� 5 eCi�s.s G �t`�r �� f 1 ❑ Stk 466-6781 ❑ 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. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED DK RECEIVED BY - DATE PERMIT'NO. 1. INFO CASH Hi 13.24(REV.1/8 5) k EH 14-26