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x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 11 V 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES1 YEAR FROM DATE ISSUED (Complete in_ i-iplicate) 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. 1,862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. , :t J I 4 Job Addre ?. re/�.gL40 Cit>+"� Lot Size PM �JV Address _ Z� Owner's Nam � d0 J Phone�� `�� - I/ /?W Contractor'• Addres10 40'if License N PhorT� ! TYPE OF WELL/PUMP: NEW*WELCj4 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ e DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE10 FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS _ v INTENDED USE i. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing G lle Domestic/Private Spy Gravel Pack ❑ Tracy Type of Casing Specifications Public Other ❑ Delta Depth of Grout Seal t�V • " Type of Grouter I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by 0,V7- C - Repair Work Done 'El` Type of Pump . H.P. _ State Work Done _ Well Destruction ❑ Well Diameter Sealing"Material1top 501. - Depth Filler Material Melow 50'1 TYPE OF SEPTIC WORK: . NEW INSTALLATION I'I," REPAIR/ADDITION 1 I--DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other . t 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 d LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Property Line j 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 District. I 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: "l 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 must call f r all lrrlquire d inspections. Complete drawing on reverse side. 7 Signed X Title: 01f.aA-or. Date:��" FOR DEPARTMENT USE ONLY Application Accepted by Date I r Area` 0 Pit or Grout Inspection by Dat JJ Final Inspection by Date 14 Additional Comments: r V { ru `�` t �^ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �✓` . rdrrwj=z-� T'ff 6,L_ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 ;t FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'-NO. INFO CASH +.EH 13-24(REV.t/k51 776 00 1913 ° ?4--,2 NT EH t4-2e -