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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601E. HAZEL T ON AVE., STOCKTON, CA t,. q 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. = i t Job Address —/7- -lJ � City 1-,Odll, Lot Size 9_r.?Vd Ply 1 p I Owner's Name L • t r Address —4 ,VjO / Q "/:la Phone J .�a� Contractor Address 4(W- License No.,&f7ju Phone eTYPE OF WELL/PUMP: NEW WELL$" WELL REPLACEME -❑ � DESTRUCTION Ll r PUMP INSTALLAT 'SYSTEM'REPAIR ❑ 'A OT ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE + FOUNDATION AGRICULTURE WELL T_ �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 "Y l� Domestic/Private Gravel Pack ❑ Tracy Type of Casing g �.�.4�.. . Pecifications„,��d.�i Il Public 17 Other Cl Delta _'--""'•Depth of-Grout"Seal"""� Type of Graut (Kty YP Irrigation ` y 9 --Approx. Depth I 1 Eastern 5u`rf,ace §eal Installed by i Repair Work Done ❑ Type of Pump X, H.P. o State Work Done— Well Destruction 11 Well Diameter Sealing Material (top 50') f Depth Filler Material (Below 50') e r i i TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTION i I (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms r 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 ° L~ Distance to nearest: Well Foundation Property.Line u s LEACHING LINE ❑ No. & Length of lines Y� - ` �+` Total leg size - _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth ______2L Size Number .� SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line (> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws;•end 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 applicant must call or all quired ins ction . Complete drawing on reverse side. N Signed X = Tide: Aei i Date: FOR DEPARTMEN USE ONLY Application Accepted by t Date Area f I Pit or Grout Inspection by Date Final Inspectiomby. Date Additional Comments: ❑ Stk- 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 d Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE !AaMOUNTEMITTED CKRECEIVED l3Y DATE PERMIT'NO. INFOCASH -.� +.EH 13-24(REV.i/x 51 /O Com— EH 14-28 \J