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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.E. HAZE T ON AVE., STOCKTON, CA �� Telephone 12091 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 1he 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. �y y Job Address c-2-� 7 � D�o}f� I ' �—� City Ar, iF 0.-- Lot Siz"'+`f3��C�I�U r PM Owner's Name �1.5 Address 1�1 19�L I L�R Phone3 Contractor r h Address License No.c Phone TYPE OF WELL/PUMP: NEW WELL.�4- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION)9- SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK 1S O SEWER LINES DISPOSAL FLO. PROP. LINE ` J FOUNDATION . AGRICULTURE WELL _OTHER WELL PITSISUMPS Z) r} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial Open Bottom ClManteca Dia. of Well Excavation -.'�L Dia. of Well Casing 'XDomestic/Private ❑ Gravel Pack © Tracy Type of Casing ->-7,e, Specifications ` ,p �J I'] Public n Other n Delta Depth of Grout Seal g Type of Grout 1 1 Irrigation 0-102PApprox. Depth I ) Eastern Surface Seal Installed by I_/_ 9LTe_ P—, f>1 Repair Work Done ❑ Type of Pump ;S t2bi_ H,P. ..3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 -- V Depth Filler Material (Below 501 —1 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION 1 1 DESTRUCTION I i 1No septic system permitted if public sewer is VJ 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ..w Method of Disposal Distance to nearest: Well Foundation Property Line (1 1 LEACHING LINE ❑ No._& Length of lines Total tength/size _ FILTER BED O Distance to nearest: Well Foundation Property Line t SEEPAGE PITS [ I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line t 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." 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 Title: S t' t� S Date: f FOR DEPARTMENT USE ONLY Application Accepted by 1� tU,,S ^, Date Area _ 4:!:A _v Pit or Grout Inspections Date Final Inspection by_. Date-S�7e/� Additional Comments: F63 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835- 85 plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH 301 ♦ EH13-24fREV.tiH5Y q{�Q� � II �� f34 EH 14-26