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I � " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA j 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address C�/ �� City �/ Lot Size PM i Owner's Name r XZ Vo Address iyo N Phone r _ a J/ It�342� ;la Contractor's Name �. � ��"'/ M't Ljcense No. Phone TYPE OF WELL/PUMP: - _ __ - .NEW WELL ❑ WELL REPLACEMENT. --.-- - DESTRUCTION ❑ —+-a- PUMP INSTALLATION.V SYSTEM-REPAIR ElOTHER ❑ A. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t` DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS --INTENDED-USE- TYPE OF-WELL PROBLEM-AREA`-CONSTRUCTION SPECIFICATIONS- C1 Industrial PECIFICATIONS-❑ Industrial ❑ Open Bottom a Dia. of Well Excavation f 1 r Dia. of Well Casing ., +A Domestic/Private. Gravel Pack ❑ Tracy Type of Casing—wc_ Specifications ❑ Public Other ❑!Delta Depth of Grout Seal 100 Type of Gr_aut C mar ❑ Irrigation --Approx.Depth ❑.Ebstern Surface Seal Installed by W Repair Work Done ❑ Type of Pump H.P. tate Work one _ Well Destruction Well Diameter Sealing Material Ito ��_ Depth ;: d--� Filler Material (Below 50'1 T PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:'Residence F Commercial_ Other s Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth N 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 ❑ Distance to nearest: Well Foundation - Property Line o� } SEEPAGE PITS ❑ Depth Size Number--- SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that th_e.work_will.be_done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 9 q 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 i 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 follow( "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 Calif ia." f The applicant us#call for all wired ins ctions. Complete drawing on reverse side. 7 b k Signed � �'� Title: � Date: i FOR DEPARTMENT USE ONLY Application Accepted by f 11ti Date Area n b Q` Pit or Grout Inspection by ' ate � + Final Inspection b DateG Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 racy 835-6385 Applicant- Return all copies to: Environmental SaIth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`No. INFO `` /ig' /� .. + EH 1428IREV.101831 ��] l� �� "�` �/ 17/ g� "�7