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C APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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 a!s - b 1 Y� 2 City-S74 1-Y'1-Y'76►`k Lot Size -I�' a PM Owner's Name ��'el>�' o'70 d\ Address �� c-A fL kms- C��-c Contractor ��' Z \t Address _1� `L�G`4 I a �,�/ 4 License No3 Phone toq' �7 TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION I?f- SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK 20-0 SEWER LINES DISPOSAL FLD.L]r PROP. LINE 50 J FOUNDATION _J� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIgNS q ❑ Industrial Wpen Bottom ❑ Manteca Dia. of Well Excavation /7-- Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications f'l Public, Cl Other ❑ Delta Depth of Grout Seat ,t0 f TXpe gf Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by !///A Iy P, Repair Work Done ❑ Type of Pump H.P. Z State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 v1 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 SUMPS Ll 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 Di§trict. 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." The applicanA�stcall or all requir d inspections. Complete drawing on reverse s' e. Signed �n QJ��.i aQ 2�. Title: ' c_ ��-t' Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date t —2J6 00 Area��. Pit or Grout Inspection by 7y7 Date hJ// '`d Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. +-EH 13-24(REV.I H5) 1 C)C5, ' �..,. EH 14-26 l�_