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I } �* 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 r (Complete in Triplicate) s 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 .�� ` Jb 'f CityLot Size PM Owner's Name H/AA7—V 9=24 4 Address 17 7 6 __ q Pho-f d Contractor Address icense No.�6�G J Phoneq/ �G j TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 2-- r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ndustnal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing AIL Specifications I"1 Public "Pther F1 Delta Depth of Grout Seal 42S _ Type of GrouU0!tnA, �E? I i Irrigation _3�DApprox. Depth i I Eastern Surface Seal Installed by :1_irt+vr 424—A Repair Work Dane ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Cf ry Sealing Material Itop 501 r Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITEON E I DESTRUCTION € I (No septic system permitted if public sewer is t available within 200 feet.) { t Installation will serve: Residence_ Commercial Other ^•1 I Number of living units: Number of bedrooms 0 Character of sail to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation Property Line t 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 E SUMPS LZ 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 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, 1 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 applic t I for all required inspections. Complete drawing on reverse side. Signed Title: ,Aef Date: �A"� EP T USE ONLY Application Accepted by Date 0 Ar Pit or Grout Inspection by Date Final inspection by Date/ '7 ._o Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED- RECEIVED BY DATE PERMIT'NO. ff INFOEN 13-24 { QQ + FH 14-28IREV.lins) 3 00 1 2-71 I -