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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��'� s� �, _ ./f /L�Q (Complete in Triplicate) �P& .2 3�— Oa! O 7 Application is hereby made to the S�an,JJ'oaaquiin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or o. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. _) 4 is - - r� Job Address City C Lot Size PM � Owner's Name , ,'��Cr� ®�,,/ --- Address +`u' Phone gy.5�zo Contractor ,4 Address I La��//?i Lh �.D/X. l -License No.Yk23`/D Phone 13 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation �� / �wia. Gfell Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing ,Specifications 1-1 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 ❑ Type of Pump H.P. Stat ork 11 pe 69 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 t- TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 11 DESTRUCTION l 1 (No septic system permitted if public sewer is N' available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Ql� Number of living units: Number of bedrooms C, Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 'Capacity No. Compartments € 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 I I Depth Size Number SUMPS Ll 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 c,, 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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must zmgd5_2 uired irctions. Complete drawing on reverse side. Signed X m //� Title u�^ Date: IFD ARTMENT USE ONLY Application Accepted byPDate �/ Area Pit or Grout inspection byJ 4/1 Date Final Inspection by G' Date U c Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 8231q104 ❑ 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 RECEIVED BY DATE PERMIT'NO. INFO ` 9 CASH . H 1 -2,tasv.,i N 5s V I' a:o f c o b b� E7 3 �a '-RAV EH 134-29 '