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APPLICATION FOR PERMIT R SAN JOAQUIN LOCAL HEALTH DISTRICT ]�3L) 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. Job Address / r City / Lot Size PM Owner's Name, i�}/1f d� �f? Address f 7 C?enQ„06� dr_� Phone Contractor�� /t -� Mtti s�rJ_voa ,JG r✓�� License No.j�-? Phone 34 ems' 16 -7 7 TYPE OF WELL/PUMP: NEW WELL 94— WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1� SYSTEM REPAIR ❑ `�BOTHER 0 DISTANCE TO NEAREST: SEPTIC TANK /Ude SEWER LINES 06i"�- DISPOSAL FLYlJ1 a-e- PROP. LINE 0-'t FOUNDATION NO AGRICULTURE WELL, Ar, OTHER WELL PITS/SUMPS /SIA/*e- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 120pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Isr XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �gcZ r.L Specifications M Public Cl Other (1 Delta Depth of Grout Seal .l�Q f' _7 Type of Grout I I Irrigation ..Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i l DESTRUCTION I I (No 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 LI Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method_of Disposal Distance to nearest: Well Foundation Property Line T LEACHING,LINE ❑1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll 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. 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." Contractors 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 all re .ed inspections. Complete drawing on reverse side. Signed X__ �11� Title: _e&l -- .- Date: 7 / FOR DEPARTMENT USE ONLY Application Accepted by c ��]y Date — Area Pit or Grout Inspection by `�,[` Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 IREV.1/x 57 ©� VO r U (�� f Q�� , '33 EH t4-26 1 Vr' �- —1 �i '34