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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-67$1 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 a 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. r r Ileo .:.., �. Job Address ___-!�d �� City 4 Lot SizePM, E owner's Name C'�/1 !2 Address �� Phone Contractor's Name rZA s ! License No. l �702o� Phone "/ o TYPE OF WELL/PUMP: NEW WEEL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l L L PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARESTw $EPTIC TANK' ,SEWER-LINES- _D.ISP_OSAL FLD. _P_ROP_..-LINE._ - _.r. _f� - — FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL- PROBLEWAREA CONSTRUCTION SPECIFICATIONS w ❑ Industrial ❑ Open Bottom ❑,Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private «, ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation •---Approx. Depth -E Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump — —. --H:R— =--- State Work Done (1�1 Well Destruction D- Well Diameter Sealing Material1(top 5501 !_ Depth - ---- -- Filier-Material (Below 501 e 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 71 (No septic system permitted if public sewer is available within 200 feet.) �+ Installation will serve: Residence Commercial_ Other `7 Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: 42)b a Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments--..., PKG. TREATMENT PLT. ❑ Method of Disposal- Distance isposal Distance to nearest: �' Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines '' Total length/size FILTER BED ❑_ Distance to nearest: Well Foundation .erg-- Property Line SEEPAGE PITS ❑ Depth a5 Size _?3 Number 9` SUMPS, Distance to nearest: Well ) Foundation Property Line DISPOSAL PONDS ' ❑ 1 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 r 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 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 Califor 'The applicant call fn all re ed inspections. Complete drawing on reva side. Signed Title: /�"` Date: FO DEPARTMENT USE ONLY 0,3 Application Accepted_by4J Date �� Area Pit or Grout Inspection by ate —Final Inspection by Date Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 -E] Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. + EH 13-24IF1EV.10/83) LIS-00 -2,-I�� 9J -57 EH 14-26 F E J