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I i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE,, STOCKTON, CA i I� Telephone 4209? 466-6* I� 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 Ryles and Regulations of the San Joaquin e.: v s « ::rl iv . . Local Health District. �II � U� Job Address / a6 f• 1 "' City - 'Lot Size. - 7:• PM _ft.c,/f •: � t. ',yr: Owner's Nam Address ilq /�/ r[.�Y/[/JLlp� Phone3 �ContractLB Address_ ��._ �63 License No' a Z� Phon �� ~rd s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTfALLATION C1SYSTEM REPAIR LlOTHER 1-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE P # 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 Wel! Casing. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Otheri b E3 Delta Depth of Grout Seal Type of Grout 0 Irrigation --Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'I ►' Depth Filler Material (Below,501 g `TY.P OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /ADDITION ❑ DESTRUCTION LJ (No septic system permitted if public sewer is y �H available within 200'feet.) Ins 'llation will serve: Residence_� Commercial_ Other Nurber of living units: __/_ Number of Oredrooms Character of soil to a depth of 3 feet: SEPTlWater table depth d ;TANK - Fl�Type/Mfl Capaclty No. Compartments i PKG. TREATMENT PLT. ❑ i , / / `� F . Method of Disposal Distance,, 'nearesf:i��.11lrell = Foundation-, ri' Property Line i LEACHING LINE No. & Length of lines " Q 6 Total length/size 6 X FILTER±BED ff] Dist nce to nearest: WWeli..'�V--~_-. Foundation '/fir _Property,:Lir 5< f SEEPAGE PITS ❑ Depth IM {° Size SUMPS ❑ Distance to nearest: Well ' Foundation Property Line j DISPOSAL PONDS ❑ r� ! n: j I hereby certify that I have prepared this application and.that the work will 6e-done in accordance with-San-Joaquin-county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. -'C'`i F l Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work forµLicF this permit is issued, I shall not empioy'any, person in such,rtianner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature` certifies the following: "I cer#ify that in the performance of the work for which-this p61rmifis ssued;_L'shall employ persons suliject to warkma`n's compensa- tion taws of California." I x I= - 5- _i L rf-T 1'{ The'applican ust calSfoll Zroiredlrispections. Complete drawing on reversere. e. { Signedr ?� Title' Date' w t FOR DEP A ENT USE ONLY y I r i Application Accepted by Date 2�' �o Area 12, Pit or Grout Inspection'l k Date Final Inspection by ate i Additiohal Comments: O Stk; 466-6781 El Lodi 369421 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201FEE i INFO AMOUNT DUE,± AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. I + EH i3-24IREV.}/e57 "��4r $e=� EH 14-26