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1 I APPLICATION FOR PERMIT Qf� `✓ /J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. it�Job Address A 1® e"� Sa4_- .--a.l --� City Lot Size PM Owner's Name Address 4_053Phone 415 Contractor AWO to Address �� License No5CtnmPhone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ M PUMP_INSTALLATION ❑ _ _ SYSTEM REPAIR ❑ -OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications D M Public Cl Other El Delta Depth of Grout Seal Type of Grout — I I Irrigation ____..Approx. Depth i I Eastern Surface Seal Installed by i Repair Work Done CI Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top --- i Depth Fillet Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/ADDITION 1 1 DESTRUCTIO fNo 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. ❑ �� y TYr' Method of Disposal f - 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 I 1 Depth Size — Number SUMPS L1 Distance to nearest: Well Foundation Property Line «. DISPOSAL PONDS 0 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 Di3trict. 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;-1-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 C rnia.' w The applic t m st call fo a requird inspections._Complete_drawing on_reverse_side..�.,.,.. , __ Signed Title: UA �Q Date: O EPARTMENT USE ONLY Application Accepted by Data D- Area Pit or Grout Inspection by ate Final Inspection by Date 3 to Additional Comments: : ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601-E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 4 SH RECEIVED BY DATE PERMIT•NO- I INF 1229 �1� L/ �) + EH 14-28 EH 13 24 IREY.t/K 51 r u'V �/ '! 7 riJ 9 ) !a`�-� k