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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. L r Job Address J Sl,9�gr-N., l7 f�f��(j/ JJ f� r City Lot Size pM Owner's Name _ f. / �7Address Phone - Contractor Address_ _ � �[/' License No. , Phone Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION JlVt4A1 - YSTEM REPAIR ❑ OTHER CJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CEA ONSTRUbTCQN,SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing *Domestic/Private: ❑ Gravel Pack CD Tracy Type of dasinSpecifications ❑ Public i ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ti ❑ Irrigation ---Approx. Depth ElEastern Su fa a Sell Installed by Repair Work p p k Done ❑ Type of PumH.P. j. ' State Work D ne_ IC& Well Destruction - a_--_ ... Sea.�— _..lin-._ _ _ .� Well Diameter g Material (top 50') Depth ' 'Filler'%Mlaterial (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Ll (No septic system permitted if public sewer is available within 200 feet.) Installation will serine: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Qa SEPTIC TANK 1 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .y Distance to nearest: Well Foundation Property Line LEACHING LINE.- I El No. No. & Length of lines Total length/size ! FILTER BEAD :--� ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS -, ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify'ihat 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 oompensaWn 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 m requir ns. Complete drawing on rev e i e. I s Signed 0—� Title: Date: f� FPR DEPARTMENT USE ONLY Application Accepted 1by of 'VIS . �.� .\I ,UL _ Dam �j Area Pit or Grout Inspection b �1 Pe Y Date Final Inspection by Date � tJ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca 823-7104 ❑ Tracy 835433$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. ^- INFO ///��CA1SH + EH 13241REV.t/951 �� '1/ ( �� ``7 JE-7-- 0 EH f428 �/V! UY