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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ; PERMIT EXPIRES TYEAR 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 anrd the Rules and Regulations of the San Joaquin Local Health District. 1/ Job Address _ G City a�• Lot Size PM Owner's Name !"rQ!r'� Jkl rl f- Address ` 0 v Q 64', Phone 2- Contractor 1 CtI�X��f" t�---Address �`[ �r License No. 14 2Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONX, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IIn i 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private i❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"1 Public Cl Other ❑ Delta Depth of Grout Seal Type of.Grout II, I Irrigation Approx..Depth I I Eastern Surface Seal Installed by _ Repair Work Done ID Type of Pump t H.P. r tate Work Done Well Destruction `� Well Diameter f Sealing Material (top 501 K Depth Filler Material (Below 501 '40 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I INo septic system permitted if public sewer is C a # available within 200 feet.) of Installation will serve: Residence Commercial T Other Number of living units: Number of bedrooms I 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 tq;nearest: Well Foundation Property.Line j LEACHING LINE ❑ No. & Length of lines Total length/size -4 J FILTER BED ❑ Distance to.nearest: Well Foundation Property Line SEEPAGE PITS i I Depth t f Size Number SUMPS Ll Distance tofinearest: Well Foundation Property Line DISPOSAL PONDS ❑ [0' 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, 1 shall not employ any person in such manner as to became 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 parsons subject to workman's compensa- tion laws of Californi I The applicant s I for II ra it d inspections. Complete drawing on r rse srd �J M Signed X v Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by' Qd�� i' RvL-°` � Data i Pit or Grout Inspection by ii Date Final Inspection Da Additional Comments: ! ❑ Stk 456-6781 -❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63B5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE 'r AMOUNT REMITTED CK RECEIVED 9Y DATE', PERMIT'NO. INFO VE, ri+.EH t3-24 IREv,r i H sf J (fQ EH 14-29 , 2��i 614/ /' f J i