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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 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 I ,3 A 4R, R�Z)�� City�(1ZR/�\ Lot Size + � C , PM Owner's Name bJC1__reA.Dow Sb , Address . � Ic�CJJG LJ/l G f12. � Phone Contractor's Name License No. !�Z b Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE FOUNDATION '— AGRICULTURE WELL OTHER WELD PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM_AREA CONSTRUCTION SPECIFICATIONS *. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing " Specifications ❑ Public ❑ Other g ,❑ Delta Depth of Grout Seal A Type of_ 17 Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by Repair-Work Done ❑ Type of Pump H.P. State Work Done. Well Destruction ❑ Well Diameter Sealing Material (top 50') s Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.h Installation will serve: Residence_X Commercial. Other '" t Number of living units: Number of bedrooms Vn�' Character of soil to a depth of 3 feet: Water table depth `tel SEPTIC TANK ., ❑ Type/Mfg +Capacity No. Compartments PKG. TREATMENT PLT. ❑ E' Method of Disposal Distance to nearest: Well Foundation Property Line +1 LEACHING LINE No. & Length of lines H n / Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size t� Number SUMPS Eel Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that d 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 permii is'issued, I shall employ persons subject to workman's compensa- tion laws of California." The -licant ust call'for'alI're it pectin- . Complete drawing on`revwrse side. ---- Signed Title: Date: 7_2d2 FOR DEPARTMENT USE ONL Application Accepted by Date /W1Area Pit or Grout Inspection by Date Final Inspection by Date �b ' Additional Comments: 141 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $35385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 85201 FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CKV CASH RECEIVED BY DATE PERMIT'NO. + EH 1428(REV.101831 EH 114-28 `- U A. a u 7r�-'7i�