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G , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j� 1601 E. HAZE T ON 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 ! �% City Lot Size PM Owner's Name 11G'!/�Q�l� / Address Phone t� Contractorp Address ?�p � '� � "License No. ��S�7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0F1EFf D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D L FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM ARE NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done_ Well Destr ' n EO Well Diameter Sealing Material (top 501 _ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other J(/ Number of living units: Number of bedrooms K/�r1✓ Character of soil to a depth of 3 feet: Water to depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines 0 F Total length/size ' FILTER BED ❑ Distance to nearest: Well 4- Foundation 4- Property Line SEEPAGE PITS Depth -Z§' Size 33 — �� ,N.umber 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 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 in such ma ner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I c i 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 red giio plate drawing on reverse side. Signed X Title: Date: l / —fr7 OR DEPARTMENT USE ONLY i Application Accepted by Date 1� 7 Area I� Pit or Grout Inspection b ate Final Inspection by Datje*4`57f�, Additional Comments: '� �m� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ♦ EH13.241HEV.iixs) V�d tom. 'O^137 V / 6� �/ 6 0-28 EH 1 V -87 V