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t t 4 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. f� J p Job Address /G`t.700 N •(' �l)�L Lel City Lot Size PMOwner's Name Q L_ l !3/�/��Z- "a Adddress Pol /1�'_ hone o> p� Contractor /vUJ�� Address o 5 Psi' da l� / w� /Ol_icense No on&3 Phone c%67 ll Erc�j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT X DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.lc�?6 ' PROP. LINE 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 ©PIR' 19 Domestic/Private 19 Gravel Pack W1 Tracy Type of Casing /specifications El Public El Other ❑ Delta Depth of Grout Seal PUG-'�" /� Type of Grout El Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth `� %3 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 for all req 'ed inspectio s. Complete drawing on reverse si e. Signed Title: Date: �jy► FOR DEPA MENT USE ONLY Applica' ccepted by ' ' t ` fi Date 2T^ Area Pit r Gr C Inspection by / ✓� Date -2'/ Final Inspection by 1 Date 16 Additional Comments: L000 l d / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 17❑ Traty 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 S FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH T'NORECEIVED BY DATE PERMI . �c + EH 1428(REV.I/a 5) 7, r