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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r I � Telephone {209} 466-6781,. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a 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 C rl �'�3'1Z� City Rize ��. PM Owner' me Address -+*- f I' Pha /�v y[ C r Addres License N Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'PUMP INST,4LLATION43,-'- SYSTEM REPAIR b_'-"_OTHER ❑ ' t DISTANCE TO NEAREST: SEPTIC TANK a-SEWER LINES •- R �DISPOSAL-FLD. PROP. LINE i l _ FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑� Industrial 171 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L�'tTomestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing l 1 Specifications ❑ Public ❑ Other Delta DepWo Grout Seal ; Type of Grout ❑ Irrigation ---Approx. ep ! Eastern urSeal Inste.alled by Repair Work Done ❑ Type of Pu p H.P. "State Work Done4kZ Oik A A�.66 Well Destruction ❑ Well Diameter Sealing Material (top 501 lY _ 1 Depth Filler Material (Below 501 i./ J I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet./ Installation will serve: Residence— Commercial_ Other 1� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg Capacity-1,1 No. Compartments j PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation t - t Property Line LEACHING LINE ❑ No. & Length of lines Total length/size tr FILTER BED ❑ Distance to nearest: Well Foundation Property Line ° F I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation I I Property Line DISPOSAL PONDS ❑ 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 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 subjec"o wor man's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foil g:"I certify that in the perforn,. nc of the ork for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of if`rnia." ! y r The applic m st call for all a/qu'�d in pec Comp to drawing onhreide.Si ned /t `4! " Title• lr�,� 1r Signed Date: I R DEPARTMENT USE ONLY S i � f Application Accepted by Date' -� - Area Q # Pit or Grout Inspection by Date Final Inspection by r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy; 835-6385 'k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE . - cINFO MOUNT DUE - AMOUNT REMITTED CASH RECEIVED BY DATE � PERMIT NO. � + EHi}24[REY.i/e5) ,a EH}428 ' 1111