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i t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.; STOCKTON, CA V'��i�� Telephone (209) 466-6781 - ,�!v � II � PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED - . N\<1, ,��) (Complete in Triplicate) r Application is hereby made to tW.San Joaquin Local Health District for a permit to construct and/or install the work herein descri application is r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/pump and the Rules and Regula San Joaquin Local Health District.'... Job Address Ci Lot Size PM 1 Q Owner's Name- Contractor ame �r "L` �'�'" _- Address � 1 ��+++��- Phone Contractor!l40C4_AC&1& - _Address//72z!$4 "LG License NoM � Phone } TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ET' DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing J Or Domestic/Private ❑ Gravel Pack ❑ Tracy , Type of Casing-- Specifications l..a.r_s EI Public ❑ Other :j Delta ''Depth of G2-.rout.S-eal_ Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done Zr Type of Pump H.P. f tate Work Done Well Destruction ❑ Well Diametr.. -.....- ... Sealing Material {top 50'1 - Depth , Filler Material f0elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑' REPAIR/ADDITION ❑� DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 1= Character of soil to a depth of 3 feet: Y i Vater table depth w SEPTIC TANK ❑ Type/Mfgly Y^ Capacity IVo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 4 Distance to nearest: Well Foundation Property tine LEACHING LINE ❑ No. & Length of liI-enes Total length/size FILTER BED EJ Distance to nearest: Well Foundation Property tine t SEEPAGE PITS ❑ Depth }"' Size Number - SUMPS 1 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:"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." f t The applicant st callor all re i m ctions. Complete drawing and rse side. A2 Signed X ' Title: , Date: / - PARTMENT USE ONLY 0 (0 Application Accepted by 0 Date "' A a ��77 Pit or Grout Inspection by Date Final Inspection b dWateL 2� Additional Comments: ❑ Stk 466-6781 ❑ Lodi` 369-3621; ❑ Manteca 823`7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 (NEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <6- +EH 13-24(REV. ,Ss :".51O U k t t EH 1425 V l .