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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address 4") � oo� �f�-� _ City oc&c L�at Size G PM Owner's Name F- � 7. Address / FL L-d Ti �42 15- Phone � 0Jf Contractor Adtlress �� I� ��-fdx License No. !Je jr&?� PhoneJ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ,20 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 ! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public F Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth ( 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. J State Work Done _ 'P�rt� 4,:t"6 7W1,6 Well Destruction Well Diameter 1V- Sealing Material (top ) 1 Depth &P Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i 1 DESTRUCTION I i (No-septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other 4 Number of living units: Number of bedrooms --- Character of soil to a-depth of 3 feet: - - - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments " - +PKG. TREATMENT PLT. ❑ 1� .. Method of Disposal Distance to nearest:, Well Foundation "" - Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well FoundationProperty Line P -1 a SEEPAGE PITS 11 Depth, Size - Number SUMPS ❑ Distance to nearest: Well Foundation Property Line { i DISPOSAL PONDS p ' 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, ( shall not N employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicantm a II equip tions. Complete drawing on raver gide. 01 Signed X L �� --- Title: Date: 1141311S 7 ' FOR PARTMENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi I&Awi ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2f Stk., CA 95201 P' L FEE f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.-EH 13-24IREVf EH 1429 I y '3 S S �� X7331 i