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E E APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) I 1 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 i made in compliance with San Joaquin County Ordinance No. 54 for sewage or No. 1862 for welt pump and the Rules and Regulations of the San Joaquin ; Local Health Districtr lop 7r G:. yoyof,'�e-l '�{f G- ed ��/� 'G h-re. Job Address ,r J--�IJ / � City '�� Lot Size PM ! //f �i r Owner's Name Q r r Y' s Address Phone Contractor �IZZ �� . icense N PhDneo 'TYPE OF WELL/PUMP: NEW WELL LJ—. WELL-REPLACEMENT-❑ DESTRUCTIONS- - PUMP INSTALLATION ❑ RSYSTEM REPAIR ❑ OTHER ❑ 93 i DISTANCE TO NEAREST_ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE C> i FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications e FI Public (_1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation .__,Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P, State Work Done _ Well Destructions Well Diameter Sealing Material (top 501 � Depth Filler Material (Below 501 4 I--e I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will sere: 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 1-1 Depth Size Number SUMPS ❑ Distance to nearest: Well sr Foundation Property Line DISPOSAL PONDS ❑ --�r I hereby certify that I have prepared this application and that the work will be done in accordance with San-Joaquin county ordinances, state law d-- rules and regulations of the San Joaquin Local Health District. i, I 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,1 shall employ parsons subject to workman's compensa- tion laws of California." The applicant must call fo all equired inspections. Complete drawing on re er a side. \ Signed Xj� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Z�Q=-15!C Area Pit or Grout Inspection by Date Final inspection by r�/�, � t� -bat Additional Comments: El Stk 466-6781 ❑ Lodi -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 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO p CASH +.EH 43-24(REV.i/n 51 �J>�y 3 EH 14-26 V