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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telepho6e (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 City —Lot Size A, 'a,.- PM Owner's Name dress Phone 67 � 1 r i 1►-5 Phone -�22 Contractor ddress 1 / _License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULT E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE AR CONSTRUCTION SPECIFICATIONS EJ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Deft Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth l 1 Ea ern Surface Seal Installed by {� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material flop 50'} Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I&T REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is C� available within 200 feet.) Installation will serve: Residence— Commercial Other S 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. ❑ Method of Disposal Distance to nearest: Well-�1 Foundation 3 o Property Line A)� ]� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS l 1 Depth 2- Size Number SUMPS C1 Distance to nearest: Well Foundation _/042"J 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 Diltrict. 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 suchN manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 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 ust call for ai required in ctions. Complete drawing on reverse side. 17 Signed X Title:_tf tf�7 t2� r ,Date: �— c FOR DEPARTMENT USE ONLY 7 2 Application Accepted by { _ Date� �" i Area SPU'or Grout Inspection by Date vinal Inspection byDate� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 Cl Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE REMITTED CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT AMOUNT CASH 4 fC[7 II 1. -EH 13-;4 tREV.1 AW -2) Q0 EH 14-26 UU