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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 k Local Health District. 47 Job Address 7 23 City Lot Size PM Owner's Name1 Ad essr if - ` + Phone ' -Contractor C Address /_ 44 tin P60 f•`lLTcense No.72942 Phone i TYPE OF WE P ` P• NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL-^_ --zTOTHER-WELL— ��-('ITS-/.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 M Public 171 Other T ❑ Delta Depth of Grout Seal Type of Grout - III Irrigation ..Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump �_. - H.P. State Work Done_ V� Well Destruction ❑ Well Diameter Sealing Material (top 501 v Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I i DESTRUCTION I 1 (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 r 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 Depth Size Number t SUMPS L71 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 applica must c I for all required inspections. Complete drawing on reverse side. Signed X Title: - '+. Date: FPR DEPARTMENT USE ALY /,b— 0 Application Accepted by Date Area Pit or Grout Inspection by Date' Final Inspection by Date f Additional Comments: E7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �fy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT NO. i.EH13-24IRJ EV.1/N5} `�5 i CA IP-1 0-2-D41 EH 14-26