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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 EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ; Application is heieby 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 r CG`1C.t o 9 G rJ City Lot Size PM Owner's Name c� y`!Q rN,,? Address 7 >0 SO' �dU��L� Phone _94r705_ i Contractor Address License No. Phone `f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES M � DISPOSAL FLD-.1 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL'S i PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP `: E3 Industrial ID Open Bottom ❑ Manteca Dia. xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other a to Depth of Grout Seal Type of Grout ❑ Irrigation ppr pth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ pe of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 - f!--_Depth-_=- .-- __ _ Eiller Material (Below 501)_ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is ! X lavailable within 200 feet.) Installation will serve: Residence!' Commercial_ Other Number of living units: J— Number of bedrooms Character of soil'to a depth of 3 feet: ` Water table depth SEPTIC TANK l ❑ Type/Mfg Capacity__________L No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE "�p& Leng� th of lines"y Total length/size i FILTER BED ❑ Distance to nearest: WellFoundation ;Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation--_... ..._-__..Property Line 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 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." T applicant m call for all required inspections. Complete drawing on reverse side. Signed X w Title: Date: I FOR DEPARTMENT USE ONLY App libation AcceP Y ted, �i Date Area }- � --- Pit or Grout Inspectio Date Final Inspection by Date C 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 55201 FEE INFO AMOUNT DUE AMOUNT REMITTED— C SH RECEIVED BY ) DATE �7 PERMIT1No. '+ EH 13 EH 1a-24 261REV.t/R5i r i