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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES-7'YEAR'FROM DATE ISSUED (Complete'in,Triplicate) Application is hereby made to the San Joaquin Local Health District for a permjt to construct and/or install the work herein described.TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage r o. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address + c J Q\_0 5 City t© -'0OLot Size " �X I U PM r j +Owner;s Name � �C ON '� \t!ILI ,dress Phone �. S � CL �OI` � `t- �fPllone ContractorL�-� RST 'A_, Address lJ icense No. 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/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications --, ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r _(� Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth 41 Filler Material (Below 501 TYPE-OFSEPTIC—WORK:-NEW-INSTAL-i-ATiON-S—REPAiR/A-DDITION ftl,-DrESTRUCTION ❑ (No septic system permitted if pubic sewer is $ j available within 200 feet.) Installation will serve:] Residence�_ Commarcial_ Other'— of ther r `r of living units: r Number of bedrooms ( t umbe , r 9 a�� Water table depth t Character of soil to a depth_ of 3 feet: p � Q SEPTIC TANK 0 Type/Mfg capacity—j— No.,Compartments PKG. TREATMENT PLT. ❑ - w"4 r Method of Disposal o 'Distance to nearest: Well Foundation � Property-Line - LEACHING LINE Co. & Length of lines v '` 3 Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation 1 Propeity Line SEEPAGE PITS ! 0�Gepth D�5 - '�Sti7e_�`� t Number 1 SUMPS ❑ Distance to nearest: Well Foundation Propeity Line ! DISPOSAL PONDS -❑. r hereby certify that I have prepared this application and that the work will be done in accordance'w'ith.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 rtifies the following: certify that in the performance of the work for which this permit is issued, I shall*employ persons subject to workman's compensa- tion of California." 1 ' T plican ust,calI for all red i s ctions. m drawing reverse side. t I Signed K Title: Date: FOR DEPA E T USE ONLY Application Accepted°by r Date � l.rl a r —�-�°'y"Pi or G'tourlr1s0inn by � a e 'Y'"Finall7nspection by Date f Additional Comments: ly t�,- ��"' �� C�� O� ��✓� ` ' ❑ Stk 466-6781 ❑ Lodi 369621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permrt/ a as 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 500t, 414.6•i.I i,/.t oil, V6.3 t Ca$-0*90 Jp e. J04%) rot. r FEE DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY - +EH 13-241REV.1/85} EH 14-26