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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1,601 E. HAZE`TON 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 41�= 1617 t0 4,y-eCity Lot Size PM �J Owner's Named �` �(��1 � Address ��Ox 3� �Xlt[� 4rZ?!`xQ Phone 's Contractor C62Cf/JC0'r` Address t ( J_ f{t th,711e• License No. I -, -z.2-P�Phone L0-t2-?�L 's TYPE OF WELL/PUMP: NEW WELL 795 WELL REPLACEMENT ❑ DESTRUCTION El` PUMP INSTALLATION El R SYSTEM REPAIR ❑ _ OTHER ❑ i ry 0 DISTANCE TO NEAREST: SEPTIC TANK'-_ !� zf SEWER,LI.NES., DISPOSAL FLD. or/t—• PROP. LINE _SL r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE°OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATI 19S C/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio I Dia. of Well Casing DeDomestic/Private IX Gravel Pack ❑ Tracy Type of Casing Va f Specifications �'APC, M Public ❑ Other n Delta Depth of Grout►Seal ��.. Type of Grout oe I I Irrigation _._Approx. Depth *astern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. " '� State Work.Done Well Destruction ❑ Well Diameter Sealing Material (top 501 .� '^ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 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 .4 ..� l fy Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size j 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 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, `state laws, and i 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 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 st call f r e re inspections. Complete drawing onreyetrse side. Signed X Title: _� Date: FOR DEPARTMENT USE ONLY w i Application Accepted by Date /x'2 Area ` Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �P'ERivirr'N^tO. ♦..EH13-24(REV.Ii n 5) EH t4-284�i 4,-- 1 y