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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Local Health District. ` ?1 Job Address / �Z.- 'If�(7�! $j," .¢_ City of Size PM J Owner's Name Address AlPhone Contractor .�_ Address Q b r� Sr3 6 License No. 3f6 Z C Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONYQ I SYSTEM REPAIR J OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION_ — - -AGRICULTURE WEL-L� OTHER-WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it �•Iaddr,Etrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Priv to ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Irl Public n Other F1 Delta Depth of Grout Seal A Type of Grout ! I Irrigation --Approx., Depth I I Eastern Surface Seal Installed by Repair Work Done Type of ILPump, H,P.;9- State Work Done rL w Well Destruction ❑ Well Diameterf Sealing Material (top 50'1 + L--e--40�9 Depth f Filler Material Welow 50') I TYPE OF SEPTIC WORK; NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is' NInstallation will serve: Residence Commercial_ Oiher available within 200 feet.) Number of living units: Number of bedrooms Characief of soil to a depth of 3 feet: �SEPTIC TANK r Water table depth ❑ Type/Mfg Capacity No:'-Compartments 4/► PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to-.nearest: Well Foundation �`' R Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance toIneatest: Well Foundation �.� Property Line SEEPAGE PITS f I Depth ; Size — r T Number SUMPS 0 Distance to nearest: Well Foundation Property Line ,,,..�.-. -- DISPOSAi-PONDS,-....:..❑. rules and regulations of the San Joaquin Local Health District. 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 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 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 thisermit is issued, I shall employ 3 tion laws of California." p p Y Persons subject to workman's compensa- tion i The applicant mus r II required ins ns. Complete drawing on r rse side. Signed X ; Title: . 13-- — C) - Date: FOR DEPARTMENT USE ONLY Application Accepted by Data Area 4& -7a Pit or Grout Inspection by Date Final Inspection by Date Z Additional Comments: i, ❑ Stk 466-6781 ❑ Lodi 369.3621: } ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk- C I ;TE FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY CASH DATE PERMIT NO. +.EN 1124,REV. it 11- Erind -'{"� - , HEALTi� � F1„-26to o P T. IS