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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'l YEAR FROM DATE ISSUED, �t(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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Inc.- Job ilt;Job Address City. ;tv , Lot.Size PM Owner's Name' C 7T V /q/�8 5- s - Phone —3� Contractor Address ,�21,?_d Afie1,4 rte—License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR iP UP40qRn'- OTHER ❑ y DISTANCE TO NEAREST: SEPRi ,TANK_ SEWER-.LINES _ DISPOSAL FLD.- 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 21 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications LJ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --4pprdx. Depth ❑ Eastern Surface Seal Installed.by Repair Work Done ❑ Type of Pump H.P. State Work Done /i�!_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') L. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r' 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 t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ID Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LF No. & L'ength of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - Property Line f + --SEEPAGE PITS ❑' Depth " =Size T Number 4 . SUMPS ❑ Distance to nearest: Well. Foundation Property Line" DISPOSALONDS ❑ i 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. ,r Home owner or licensed agerii's signa{ure}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 she 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 fo all re "e inspections. Complete drawing on rave?e e. f Signed XTitle: i Date: t FOR DEPARTMENT`iJSE ONLY _ � Application Accepted by /' Dare Ar - ; Pit or Grout Inspection by I l Date Final Inspaction b Date f ,�� Additional Comments: ` i ❑ Stk 466-6781 _LJ Lodi 369-3621 t.9L Q_Manteca_823-7.104 Q Tracy-8355-6385 Applicant- Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952b FEE INFO AMOUNT DUE. '41AMOUNT"REMITTED ' (CASH RECEIVED 6Y DATE PERMIT NO. + EH 1324 iREV. i987 EH 14-26