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i APPLICATION FOR PERMIT k O SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ' Application is heieby 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. ^ r Job Address City Lot Size PM 1 ? r Owner's Name ddress `, Phones �_ �� IV 1AIr 99 3; Contractor Address ✓f �, b119.1 0 .6c"ense No-9—?L25-7—Phone 31 39 TYPE OF WELL/ P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ "PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "FOCENDATIDN"'- A7iRICl9f Tt1FS 'WELL `°' OTHEWWELL°•F "'PITS-/SUMPS--- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I` Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public F) Other n Delta Depth of Grout Seal Type of Grout 1 Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done D Type of Pump -2:RAhAg H.P, _ __ State Work Don - Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is I Installation will serve: Residence Commercial available within 200 feet.) Other .4 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 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS �,.Lq—Distanee;io=nearest;,_-Wellg- --_�Foundation-�-.—�,.��„ .P_roperty.Line- DISPOSAL PONDS Q - =..- 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."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 applican ust c or,all required inspections.pections. Complete drawing on reverse side. Signed X Title: G(sX y a Date: RTMENT USE ONLYApplication Accepted byVV2�—K4—z; r Date G Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: f! Q Stk 466.6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. r.EH 13-24(REV"t EH 14-28 .v^