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r a 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 (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. 5-Jl 15x, !�t7 Job Address City fl/ - Lot Size PM Owner's Name Address �✓C�-�r /il�/��i/� /� Phone . Contractor rjl�V X12 Address —License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public i l Other ❑ Delta Depth of Grout Seal Type of Grout--- I rout______I I Irrigation _.._ Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence_ Commercial— Other L Number of livir�g units: 0&115 Number of bedrooms T_/.& 1D l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ESE Capacity I_M QCts No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED U Distance to nearest: Well 7 Foundation — i Property Line SEEPAGE PITS i 1 Depth Size Number SUMPS Cl 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 Di§trict. 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 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 call forall r d inspections. Complete drawing on reverse side. Signed X i Title: Date: w OR DEPARTMENT USE ONLY Applica Accepted by Date Area C�i�r rout on b ata ` Final Inspection by Date II ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Ma ace 623-7 ❑ Tracy 835-6M5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE p (P�ERRMIT'ND. + EH 13-24(REV.)/n51 1r co b3q� /„ /�� iy _ 7/ tcH 14-26 ��j/ (C� 11 (J"�— /