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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA r] 10 Telephone (209) 466-6781 �i 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. City 'Lot Size_C— PM �y Job Address Owner's Name ►��IL n _1 Al C _ AddressX Phone Contractors VD ►aJOD�—Address L License No. Y.7 Phone fo.i`"fig TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 71 STEM REPAIR ❑ OTHER 1-1 DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'i Public �❑ Other D Delta Depth of Grout Seal Type of Grout P 1 1 Irrigation !A '..Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done El Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'I F Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION I I {No septic system permitted if public sewer is available within 200 feet.] Installation will serve:`':. Residence Commercial✓ Other k fly Number of living units:' A Number of bedrooms Character of soil to a depth-of 31 eet: Water table depth + SEPTIC TANK ❑ Type/Mfg _(>7e'L — Capacity_ 4a41 No. Compartments l PKG. TREATMENT PLT. ❑ Method of Disposal pistance'to nearest: Well _ Foundation Property.Line X47 LEACHING LINE T N0. & Length of lines _ >� —40-6 Total length/size ®�r^ FILTER BED . El Distance to nearest: Well. Foundation 0� Property Line — SEEPAGE PUTS { Depth � Size� � Number_� SUMPS L� Distance to nearest: Well ZeW f Foundation 141Q 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 D%i trict. ^ 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, 1 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, i shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing'on reverse side. Signed X Q /A _-Title: 6&�Mlilk Date: -- ,.yA� FOR DEPARTMENT USE ONLY Application Accepted by * Date Area / 2__ or Grout Inspection by Dater 3 Final Inspection by � Datr �" Additional Comments: t-� ❑ Stk •466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 636-6385 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' CK RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24{qEY.i/x 51 - EH 1426 _ _