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APPLICATION FOR PERMIT 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'Ordinanca No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. .� 7 t p Job Address O� City r/t C-+ Lot PM Size 9 � Owner's Name f- e O t Address -_,�f45 - Phone Contractor—Aa-Lt.��Address License No0��' —Phone TYPE OF WELL"/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ _DESfRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK-- SEWER LINES DISPOSAL FLD. PROP, LINE L FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t. Dia. of Well Casing 171 Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing-- Specifications f'1 P60lic 1-1 Other Cl Delta Depth of Grout Seal 7 Type of Grout I I Irrigation _Approx. Depth I I Eastern � Surface Seal.Installed'�by.�, - Repair Work Done ❑ Type of Pump H.P. ` ''- State Work Done Well Destruction ❑ Well Diameter Sealing_Material {top-EO Depth -filler-Material IBeln X50'1 ' -- TYPE OF.SEPTIC WORK: NEW INSTALLATION fR'EPAIRIADDITION`t-I DESTRUCTION i I_ tNo septic system permitted if public sewer is i ,.�' favailable within 200 feet.) Installation will serve: Residence Commercial_�-"Other 4 Number of living units: --I-- Number of bedro6ms,_3 " Character of soil to a depth of 3 feet: G _ Water table depth SEPTIC TANK ❑ Type/Mfg / Capacity :'— No. Compartments PKG, TREATMENT PLT. ❑ `j Method of Disposal Distance to nearest: Well Foundation/d Property Line . LEACHING LINE No. & Length of line Totangth/size t FILTER BED ❑ Distance to nearest: Well Jt Foundation Property Line { SEEPAGE PITS ( I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation v, Property Line DISPOSAL PONDS ❑ ,. µ I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. . .,.r ,:J_ - - - 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'scomp6nsation 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 for r ed ins coons. Complete drawing on reverse side. 4 w Signed X i Tity - � e �.-..__ - FOR,DEPARTMENT USE ONLY Application Accepted by F Date o ea Pit or Grout Inspection by Date Final Inspection by 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 IFEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24"(REV-t'ixsi _... -70 - �� EH 14-26