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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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'loaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` !/ J Job Address *�`� �9�7 U / City Lot Size 111X / �/ PM Owner's Name [.��/�//CL_�it/�/�l/ Address ✓ 7 4� Phone 337 /S Contractor Gf/ s �F Address 126c2 l �G1/�llC� License No.�y�` Phoney1�9 TYPE OF WELL/PUMP: il: NEW WELL WELL REPLACEMEN DESTRUCTION ❑ PUJMP INSTALLATION SYSTEM RE PAIR ❑ OTHER❑ , r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD��_v.1IPROP. LINEW_ FOUNDATION �.r� ! AGRICULTURE WELL OTHER WELLr.._ C PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . . V Domestic/Private 01 Gravel Pack ❑ Tracy Type of Casing S-/G/ZSpecifications F1 Public .Ch Other ❑ Delta Depth of Grout Seal 150" Type of Grout9 ' I I Irrigation p .Approx. Depth l l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. -� State Work Done Well Destruction © Well Diameter �d Seating Material )top 501 .� Depth X20 Filler Material (Below 501 T f TYPE OF SEPTIC WORK: NEW INSTALLATION i I P.EPAIRIADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is V I�� available within 200 feet.) I' Installation will serve: Residence_ Commercial_ Other I 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 r LEACHING LINE ❑ i 'No. & Length of lines Total length/size FILTER BED ❑ !Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1. 1Depth Size Number SUMPS Cl 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 'Y 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 I 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,l shall employ persons subject to workman's compensa- tion laws of California." 1111 The applicant must call for aa1�ll//require spections. Complete drawing on reverse side..p p r Signed X �"zA " Title: 06MAIe/� Date: HIS FOR DEPARTMENT USE ONLY J ill Application Accepted by Date 9�Area 1p ' Pit or Grout Inspection by �I Date Final Inspection by 7�-4� lct - Date Additional Comments: r Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 S 7 Applicant- Return all copieslto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMMO"UNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH �.EH114-28 3.24 EH 1REV.iiris) rl(✓ �� ;�t/s•� 47�� },� J �r a yah Rt �r t