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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 S� J` / L, City 1� Lot Size PM Owner's Name Address ��Z S1 GC Z y�c� La Phone 0� Contractor �� rl ,, Address Nn phone Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEVr ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTW"REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.," DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU RE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout __ I I Irrigation rox. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ e of Pump H.P. State Work Done_ Well Destruction Well Diameter Sealing Material (top 50') 4 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIO DESTRUCTION I I (No septic system permitted if public sewer is 1J\ � 1 Installation will serve: Residence� Commercial_ Other available within 200 feet.) r v Number of living units: -J-- Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 70 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE IK No. & Length of lines - Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation ffl r Property Line SEEPAGE PITS I I Depth Size ✓ /O _ Number Z SUMPS LA' Distance to ne rest: Well /CIC Foundation e? 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 Diltrict. 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 applicant must c for all required inspections. Complete drawing on reverse side. Signed X Title:� Date: ` Z FOR DEPAR MT ENT USE ONLY Application Accepted by _Z� Date o Area 1 Cys Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: --C- /'�'� l�n ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 b Tracy 835-6385 Applicant- Return all copies to: Environmental Health ffmit ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUEiiiEMITTED\ INFO ��,//('''�� CASH RECEIVED BY DATE PERMIT'NO. lJ + EH 13-24IREV.1i85) � /0 /A/1 7� L_� EH 14-28 / i l/N'l�l` J