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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE:, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I.YEAR FROM DATE ISSUED .., IComplete 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 Local Health District.;; Job Address / '� � City 5Tt Lot Size PM _ ' 6pp 73` QST Q Pfilorl� �QZ Owner's Name �7 �C ' Address - Contractar� S Address ri�124 LU/ f2 License No. (T 4! Phone j TYPE OF WELL/PUMP: NEW WELL'nr, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALL-ATION-�k4pA Ve SYSTEM REPAIR ❑ OTHER ❑ `� `t_SEWER LINES DISPOSAL FLD. PROP. LINE I DISTANCE TO NEAREST:.SEPTIC TANK +4 �." FOUNDAT16N y AGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom �M,6teca Dia. of Well Excavation Dia. of Well Casing .�omestic/Private ❑ Gravel Pack Tracy Type of Casing j Specifications ❑ Public El Other Ito Depth of Grout Seal Type of Grout t h}T i ID Irrigation ---Approx. Da th ❑ Eastern t5 rface Seal Installed by i i A V Il Repair Work Done Ll Type Type of Pump I H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material lBelov K- ) i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septics stem perm ed if public sewer is available within 200 460 Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water able depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El , 1.' MethA of Disposal Distanceito nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lin SEEPAGE PITS ElDepth Size Number I _ t ' SUMPS 11 Distance to nearest: Well Foundation Propertyn DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance withlSandoaqin county ordinances, state laws, and ! rules and regulations of the San Joaouin 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." Contiactor'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 pirsons subject to workman's compensa- tion laws of California." f �" � The applicant mWil all r ;spections. rawing on r e ide. �J l Signed Title: Date: 7 FOR DEPARTMENT USE ONLY } Application Accepted byDate Area Q Pit or Grout Inspection by' � Date Final Inspection by f + ' Date a �� Additional Comments: kStk 466-6781 ❑ Lodi 3t9-3621 ❑ Manteca 823-7104 ❑ Tracy 8354KM " Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO �[1�►�� 7 �] + EH 13-24 IREV.1/e 5) '�s �-^ "]�— -`lA r 2-11-7,-1 Z V jf l EH 1428 f