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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT >1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone 12091 466-6781 N ('} t K t } PERMIT EXPIRES 9 YEAR FROM DATE ISSUED t r (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I ' Jab Address DC Q Q.�L r ta�( � Y�C� City I Lot Size p I Owner's Name - f�L1 f P Address J✓I.P . Phone j �+ Zs: o�i�alt�, 9 ' 1Srd_ Contracto Address License N Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑' � 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' ` � ' t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I ❑ Public ❑ Other C1 Delta Depth of Grout Seal Type of Grout E f � ❑ Irrigation_ --Approx. Depth _ ❑ EasternSurface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done • € ii Well Destruction 17Well Diameter Sealing Material (top 50') r� Depth Filler Material (Below 501 l# I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT ON o septic system permitted if publid'sewer is available within 200 feet.) { Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: s Water table depth F I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i I PKG. TREATMENT PLT. ❑ Method of Disposal {I 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 ' t i r SEEPAGE PITS ❑ Depth Size Number 1 SUMPS ❑ Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ 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 District. 1 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 1 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 California." The applicant call for all required s tions. omplete drawing on reverse side. 1 Signed Title: Date: + a F DEPARTMENT USE ONLY . Appl' n Accepted by Date Area - Pit or Grout Inspection by Date Final Inspection by Date, / Additional Comments: �3~� f 1 ry C - Lee ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 I Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 YWO 14r-e•6.,oFEE d"� ccs Fwd rr.� �i�r'►` [ INFO AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT"No.,� � + EH 1428(REV.1/e5} 4� ,/