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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.--18.62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.` Job Address Is, 0'nff City Lot Size PM Owner's Name t.� �, Q T S Address iS-3��15-�Qazu Phone Contractor �1�lll1 Address�J® �1 Q V �, License No. Phone `r 70 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout_ I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'i Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION L 1 DESTRUCTION I 1 (No septic system permitted if public sewer is C1 available within 200 feet.) J' 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 f n PKG. TREATMENT PLT. ❑ Method of Disposal V Distance to nearest: Well Foundation Property Line n LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line G E _r SEEPAGE PITS l I Depth Size Number r 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. 1 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 applican t call or all uire inspections. Complete drawing on re ere side. Signed X 't Title: �I' - � _ Date: FOR DEPARTMENT USE ONLY y ' i Application Accepted by �' Date S 7e Area Pit or Grout Inspection by Date Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIV INFO ED BY DATE PERMIT'NO. � �3''y,�Y EH 144-28 ( 7QCJ (ISS//