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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON 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 i Local Health District. Job Address ` v fU� City 1 � t�LSize-1 x SO PM Owner's Name __3Lf t `L'� �� ddrasseq lqf�_ Phone Contractor Address License Ni . Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 , PUMP INSTALLATION ❑ SYSTEM REPAIR 71 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ClIndustrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing I 0 Domestic/Private- 0 Gravel Pack 1 O Tracy - -� � Type of Casing--= --- Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. 11 Irrigation —.-Approx. Depth 1 1 Eastern Surface Sea! Installed by - Repair Work Done 0 Type of Pump I H.P. State Work Done Well Destruction ,( ❑ Well Diameter Sealing Material (top 501 + Depth • Filler Material (Below 50'} bF TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— 'Commercial- Othe—r Number of living units: Number of bedrooms Character of soil'to a depth of 3 feet: ` 4 Water table depth SEPTIC TANK 0 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Wel! Foundation Property Line DISPOSAL PONDS ❑ .� 1 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. Horne 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 shalt not employ any person in such mannn'r as to became 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 parsons subject to workman's compensa- tion laws of California.;11 i The applicant must call for all required inspections. Complete drawing on reverse side. P # tg - gf� Signed Title: `Q� f - r Date: FOR DEPARTMENT USE ONLY I } + Date Area_. Application Accepted by„ .c. . Pit or Grout Inspection by Date Final Inspection by Date kdditional Comments: R e- �"� Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 p &_,4- plicant- 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 AS RECEIVED BY DATE PERMIT'NO. INFO �] j�/[/� + EH 13-2�(REV.i/H 51 L �� !�/ (J�oL� EH 11-28 ✓✓