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APPLICATION FOR PERMIT t}r 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 `7 D ` �� r City® � Lot Size 90 YQ PM f� , f r ` - ' r j a Owner's Name !/ r`I ��-_ ! W Address / { UJ' 'h! f (6) I J Phone T /'' 'f® � N e �d ?' 4 � '01t D I,I,,� 3-� Contractor ! ddress r Icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ PUMP INSTALLATIQN,.O'. SYSTEM-REPAfR-EC '"""""""""""-OTHER°❑. :�"^y- -� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE L FOUNDATION AGRICULTURE WELL OTHER WELL .- PITS/SUMPS .— yam` -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 C1 Other. Cl Delta Depth of Grout Seal Type of Grout I I.Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installed by (v� Repair Work Done ❑ Type of Pump H,P. Staie Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1 l DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other 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. ❑ r _Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total 199th/size Y FILTER HED ❑ Distance to nearest: Well Foundation SEEPAGE PITS 1 I Depth---- Size Number SUMPS ❑ Distance to nearest: _ P WeII Foundation Property Line DISPOSAL PONDS C7 +:> ` 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 Di%trict. Home owner or licensed agent's signature certifies the followings "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 in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion lawsof C lifornia., j the applic nt uswa for al req d inspections. Complate drawing on reverse side. © Signed X `� t Title: _011_ rn��. Date: '1' 0-9 F EOR MENT USE ONLY rt y1 r Applicetion`Accepted by Date Z Area�l o Pit or Grout Inspection byDate �: Final Inspection by Date 2 _ I Additional Comments: _ _ „ e-D it , ❑ Stk 466-6781^ ❑ Lodi -3621 I ❑ Manteca 623-7104 ff Tracy 8 --6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . J FEE-- AMOUNTDUE ' AMOUNT RENIITTEO C HE BY- DATE el PERMIT'NO. INFO +.EHt3-241REV.1/Ks) - !/�} C�JJ� t-• LJ - � y