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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 Districct^ '] p Afi r Job Address a / I l� lG5�lc_",tj(i _ CityS �C� �� Lot Size AC— PM '75Owner's Name RA AA fat._. (Z h6+ Address I FFQ C � '° Phone f Contractor &tt��S GL1� Address i W44 S ' License Ko. Phone -?407 TYPE OF WELL/PUMP: NEW WELL X. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION kr SYSTEM REPAIR ❑ OTHER ❑ / DISTANCE TO NEAREST: SEPTIC TANK IDLtt SEWER LINES /0 r DISPOSAL FLD.1�� f PROP. LINE rrr FOUNDATION k0_ AGRICULTURE WELL , OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST14UCTION SPECIFICATIONS ❑ Industrial A Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing FL Domestic/Private ❑ Gravel Pack ❑ Tracy Type of C ing S TFe- Specifications 12— L`l Public 1-1 Other FI Delta Depth of Gr Seal i i Type of Grout I I irrigation __-Approx. Depth i I Eastern Surface Seal Installed by irlagrL �E'!(1� ,�1 s9.r�'��f a� Repair Work Done C7 Type of Pump Si'l h H.P. 3 . State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is _ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ 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 Dittrict. 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 applicWtuwtfljor all faquired in pe tions. Complete drawing on reverse side. p Signed X Title: Date: FOR DEPARTMENT USE ONLY Applicatio Accepted by Date � y Area 2 Pit orro Inspection by to 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 955201 INFQ AMOUNT DUAMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMtT�NO. +,EH 13.24(REV. �. rS EH 14-26 lJ