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APPLICATION FOR PERMIT 00 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 f PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 'I (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. City Job Address, t/ Lot Size PM l; ! Owner's Nam. -l' L( [�iZ/yrtf Address-Z f �� `-trr Phoned `F r Contractor , _&Z ®��< Address c-- �"" License No.� - — Phone "�' r TYPE OF WELL/PUMP: NEW WELL�C WELL REPLACEMENT ❑ DESTRUCTION ❑ li PUMP INSTALLATION 1Z' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK z SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J ri [IIndustrial ❑ Open Bottom ElManteca Dia. of Well Excavation _ Dia. of Well Casing is t �.� .Ci�t-u I� L� Domestic/Private 'Gravel Pack C1 Tracy Type of Casing Specifications- f M Public Ll Other Cl Delta.' Depth of Grout Seal Type of Grout I i Irrigation _Approx. Dept 1 1 Eastern Surfpce Seal Installed by r Repair Work Done ❑ Type of Pump ' ' H.P. State Work Done -Z- Well Well Destruction ❑ Well Diameter Sealing Material atop 501 x 4 ti Depth Filler Material (Below 50'1 0 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 1 *DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other r 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. ❑ 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 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 iri the performance of 1he work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ; j The applica ust_ all for.all.rgquireddnspecti4nlComplete_drawing on_ verses _ ide. ,... Signed X ' itle: �.1�� Date: `� I `f V r __=ZMiR DEPARTMENT USE ONLY Application Accepted by Led �A " �"w`' ��•!�_ Date U `' Area - /, Pit or Grout Inspection by ` Date Final Inspection y'� 1 i/� — Date 40 Additional Comments: . G`� t 2 r ( � t PSev, 2 ❑ Stk 466-6781 ❑ Lodi 36913621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ` + EH 13-24(REV.s/w sl Irj D q j EH 1920