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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 District. i Job Address - / City�� Lot Size PM Owner's Name `d t Contractor T� B%DWAddress License No ©as.44 honA_! �/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SU S _ INTENDED USE TYPE OF,WELL PROBLEM AREA CONST RUCTID NS ❑ Industrial ❑ Open Bottom ❑ Manteca D" ell Excavation Dia. of Well Casing ` El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public F ❑ Other alta Depth of Grout Seal Type of Grout I I Irrigation A epth i I Eastern Surface Seal Installed by Repair Work Done ype of Pump H.P. State Work Done_ Well Des n ❑ Well Diameter -^-Sealing Material (top 50'I Depth Filler Material (Below 501 j TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1, REPAIR/ADDITION 1 I DESTRUCTION>ClNo septic system permitted if public sewer is f ,available within 200 feet.) , Q r Installation will serve: Residence Commercial. Other �iwr�yd4/j� �xrT/11�¢ t Number of living units: Number of bedrooms 7,22 ✓ E Character of soil to a depth of 3 feet: Water tab e d pt SEPTIC TANK ❑ # Type/Mfg Capacity No. Compartments E PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line IJ - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ " Distance to nearest: Well Foundation Property Line 1 _ SEEPAGE PITS 11 Depth j Size Number SUMPS ❑ Distance to nearest: v Well Foundation Property Line DISPOSAL PONDS ❑ IR , I hereby certify that I have piepared 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. 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 ch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin 'I certify that in the performance of the work for which this permit is issued,1 all employ persons subject to workman's compensa- tion laws of Califo i The appli m call II re Complete drawing on averse si Signed Title: L Date: UIr� i FOR DEPARTMENT USE)4Y / U Q Application Accepted by _ _ Date a Area '-{/� � Pit or Grout Inspec n by Data specs "�� Date F! C'- v Additional Comments: ❑ Stk 466-6781 0 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 95201 INFO M AMOUNT DUE' AMOUNT REMITTED CK ASN RECEIVED BY DATE PERMIT'NO... 1r• +.EH 13-24ISEV.rir,sf yr .Pi 3G72� l_j6-1 . EH 14-2e "'"`rrr"'[[[ .-�