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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3601 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. 1862 for well/pump and the.Rules and Regulations of the San Joaquin Local Health District _ 41 a-sem � � ! • Job Address City Lot Size . PM_ Owner's Name Address:` c Phone — T R3 I� Contractor's Name ✓ I. vense'No. P '`' Phone /Q L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑-w- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �❑. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE, - _ • FOUNDATION AGRICULTURE WELL _\I' OT11ER WELL" h'-I%PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONrx 1 1 El Industrial ❑ Open Bottom O Manteca Dia, of Well Excavation Dia'.—,f-Well Casings W, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications_ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �.Type of Groutk �+ ❑ Irrigation ___Approx. Depth ❑ Eastern Surface Seal Installed by 21�4` s Repair Work Done ❑ Type of Pump r H.P. i —State'Work Dorie Well Destruction ❑ Well Diameter Sealing Material (top 501 j Depth f Filler Material (Below ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is! ; available within 200 feet.) Installation will serve: Residence °' Commercial_ Other Number of living units:--I _ Number of bedrooms 1-3 2 Character of soil to a depth of 3,feet: n Wa er abJs�d1e�n,'Lth SEPTIC TANK ❑ Type(AAfg QQ p i o. bnpartrhems PKG. TREATMENT PLT. ❑ —, Method-of-Disposal,- 1 Distance"to nearest: Well Foundation Property Line ` f F " LEACHING LINE ❑ No. & Length of lines Tgtal length/size FILTER BED Distance to nearest: Wellundation_ 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 intheperformance of the work for which this permit is issued, I shall employ persons subject to workman's comonsa- tion laws of California." t The applicant must call for �all lrrequire ' spections. late drawing on reyow side. Signed X r+ �YCo//mp� 7 Title: Date: 71 v FOR DEPARTMENT USE ONLY ` ` � Is Application Accepted by Date Area p Pit or Grout Inspection by ate Final Inspection by ` Date J Additional Comments: c 1 �' 3+1 r , II !� �$f Q.❑d i Cl Stk 466-6781 ❑ Lodi 369-3621 . ❑ Manteca - 104 ❑ Tracy 835 L[d n r\1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 n yam, i } IFEEO AMOUNT DUE AMOUNT REMITTED CCAK i RECEIVED BY DATE PERMIT NO.-24 i Ca * EH 1426(REV.10183) .: ,.. _f L1 ). K '�5_T/