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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job Address © '�+ - City Lot Siz 610 )(m,5 PM ' Owner's Name lt6 12 '`�'� 'Address �QwQo ®' Phone /mac L ,y o r f f Contract Address �1-11 :7 LicenseNo.� �"'Fhone TYPE OF WELL/PUMP: NEW WELL U WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE tt FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �r f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial LJOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L1Tracy Type of Casing Specifications M Public L7 Other n Delta {DeptFi of-Grout Seal Type of Grout _ I 1 Irrigation _-Approx. Depth I I Eastern ' Suitace Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (—top 501 , f Depth Filler iMaterial (Below 5M ✓ TYPE OF SEPTIC WORK: NEW INSTALLATION i I Rfi'ARIADDITIOW1. I DESTRUCTION I 1 (No septic system permitted if public sewer is Q available within 200 feet.I ' Installation will serve: Residence w . m Number of living units: ! Number of be oams.- � Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK Type/Mfg Capacity — No. Compartments PKG. TREATMENT PLT 0'* ..r .f �_ "Metliod of-Dspgsal �7, Distance to-nearest: Well Foundation Property Line 4Q5Tr 2- I LEACHING LINE `No- & Length f lines Total length/size FILTER BED ❑ 'Distance to nearest: Well/ Foundation '/- Property Line`"` SEEPAGE PITS " lJ�;''depth - Size " - Number _ r ITS / _ / SUMPS _ LI Distance to nearest: Well Foundation �8 Property Line ,DISPOS_AL PONDS ❑-�. �-.- I hereby certify,that 1 have prepared this application=and that the work will be done in accordance with San Joaquin county ordinances, state Eaws, and ` rules and�egi3[atian3 of the San Joaquin Local_He�alth'Djltrict.l 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." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c r all r q i nspec o. Complete drawing on reverse sid r��p c. ,. Signed X Title: / Date: FOR R DEPARTMENT USE ONLY Application Accepted by �`!�� Bate % T Area rr Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 it FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY7-7 DATE PERMIT'NO. INFO +.EH 13-24 taEv.I/x 5) EH 14-26